Ebook Ballenger’s otorhinolaryngology head and neck surgery (17/E): Part 1

(BQ) Part 1 book “Ballenger’s otorhinolaryngology head and neck surgery” has contents: Anatomy of the auditory and vestibular systems, development of the ear, molecular biology of hearing and balance, physiology of the auditory and vestibular systems, inner ear drug delivery and gene therapy,…. And other contents.

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OTORHINOLARYNGOLOGY

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OTORHINOLARYNGOLOGY

HEAD AND NECK SURGERY

JAMES B SNOW JR., MD, FACS

Professor Emeritus Department of Otorhinolaryngology Head and Neck Surgery

University of Pennsylvania Philadelphia, Pennsylvania Former Director, National Institute on Deafness and

Other Communication Disorders National Institutes of Health

P ASHLEY WACKYM, MD, FACS, FAAP

John C Koss Professor and Chairman Department of Otolaryngology and Communication Sciences Medical College of Wisconsin Milwaukee, Wisconsin

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Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the

accepted standard and practice at the time of publication However, since research and regulation constantly change clinical standards, the reader is urged to check the product mation sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications This is particularly important with new or infrequently used drugs Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

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infor-OTOLOGY AND NEURinfor-OTOLOGY

P Ashley Wackym, MD, FACS, FAAP

John C Koss Professor and Chairman

Department of Otolaryngology and Communication Sciences

Medical College of Wisconsin

Milwaukee, Wisconsin

RHINOLOGY

Andrew P Lane, MD

Associate Professor and Chief

Division of Rhinology and Sinus Surgery

Department of Otolaryngology–Head and Neck Surgery

Johns Hopkins University School of Medicine

Baltimore, Maryland

FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY

John S Rhee, MD, MPH

Division of Facial Plastic and Reconstructive Surgery

PEDIATRIC OTORHINOLARYNGOLOGY

J Christopher Post, MD, PhD, FACS

Professor of Otolaryngology,

Microbiology and Immunology

Drexel University College of Medicine

President and Scientific Director

Center for Genomic Sciences

Allegheny-Singer Research Institute

Pittsburgh, Pennsylvania

LARYNGOLOGY AND BRONCHOESOPHAGOLOGY

Gayle E Woodson, MDProfessor and ChiefDivision of Otolaryngology–Head and Neck SurgeryDepartment of Surgery

Southern Illinois UniversitySpringfield, Illinois

HEAD AND NECK SURGERY

Scott E Strome, MD, FACSProfessor and ChairDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Maryland Medical Center

Baltimore, Maryland

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▼ P REFACE

It has been a great pleasure to be associated with John Jacob Ballenger in the production of several recenteditions of this book and to work with Phillip Ashley Wackym in the development and execution of thiscentennial edition of Ballenger’s Otorhinolaryngology Head and Neck Surgery The central focus of the

17thEdition is the important role molecular medicine is playing in understanding the pathogenesis of diseaseand patient diagnosis and therapy in the first decade of the 21stcentury The selection of the sectional editorsand the senior authors for each chapter was based on their contribution of new knowledge to the subjectmatter of their sections and chapters through highly regarded research and their intellectual leadership of thespecialty, thereby assuring that their contributions to this book are truly authoritative The editorial aim was

to encompass the important information in all of the specialties relating to disorders of hearing, balance,smell, taste, voice, speech and language that are the principal responsibilities of the 21stcentury otorhino-laryngologist head and neck surgeon and to organize and edit it into a comprehensive compendium with anabsolute minimum of redundancy In the last ten years, there has been a great deal of international cooper-ation in understanding and categorization of major disease entities and developing consensus on patientmanagement based on these concepts; the fruits of these labors are to be found in the various sections of thebook The book is designed to satisfy the informational needs of developing specialists and specialistswanting to maintain their competence with a reader friendly source of contemporary knowledge The extra-ordinary currency of this work is largely due to the short time between composition and printing which is atribute to the publisher, Brian C Decker, and his gifted staff My gratitude goes foremost to Ashley Wackymfor his leadership, creativity, brilliant intellect and just plain hard work but in full measure to the sectionaleditors, authors and illustrators who have made this centennial edition one that will give the readerinformation, pleasure and inspiration

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The editors have expanded this edition into 101 chapters, which offer a comprehensive compilation of thespecialty of otorhinolaryngology head and neck surgery The editors chose authors who are experts in theirrespective fields who have offered reliable and authoritative treatises of their subjects Care was taken topresent the scientific underpinnings of each discipline, which provide the basis for diagnosis and treatment.The authors have endeavored to include the evidence that underlies management of the disorders.

The addition of color plates throughout the chapters has added an important new dimension to this bookdistinguishing it in the field The use of color not only conveys additional information rarely seen in a text

of this magnitude but also enhances the appearance of the book The illustration of surgical concepts andprocedures in color carries on Ballenger’s original idea of adding an “atlas” to the text

The six sections of this book cover the field of Otorhinolaryngology Head and Neck Surgery withthoroughness that includes not only the breadth of the specialty but the depth of knowledge in each of thedisciplines As it has for the last 100 years, this book provides a valuable foundation for the library of allotorhinolaryngologists head and neck surgeons

Richard A Chole, M.D., Ph.D

July 2008

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▼ I NTRODUCTION

One hundred years An interval that is longer than the vast majority of us will live After I was asked to serve

as an editor of the seventeenth edition of Ballenger’s Otorhinolaryngolgy Head and Neck Surgery, with

Dr James B Snow, Jr., I searched for and acquired a copy of the first edition of William Lincoln Ballenger’s

Diseases of the Nose, Throat and Ear Medical and Surgical, which was published in 1908 I read portions of

the original book and spent much time thinking about our field, our progress and our future opportunities

It was an opportune time to do so I was mid-career, approaching my fiftieth birthday and preparing to enter

my second decade as a department chairman My mentors and role models helped shape the person I amtoday; but, when Jim Snow asked me to work with him to develop the current edition, I was in the right time

in my life and career to be able to try to synthesize what was needed for current and future students, youngotorhinolaryngologists-head and surgeons and experienced surgeons who wanted to update their base ofknowledge Jim was the perfect person to lead me through this phase of my development He is amazinglybright, organized, thoughtful and willing to be introspective He has served as a brutally honest critic,enthusiastic supporter and father figure for me Jim has taken my critical and analytical skills honed by PaulWard, Brian McCabe, Bruce Gantz and Vicente Honrubia to another level, for which I will forever be grate-ful We established a comfortable relationship in which each person could say exactly what was on his mindand then be confident that we would each incorporate the other’s view point in improving the book—thatgoal was always foremost in our minds Jim was generous in seeking my vision, perspective and judgment

He treated me as an equal, thereby facilitating our work, and I now understand how this contributed to ing this book exceptional During the course of the development of this book, it was also a traumatic anddifficult personal journey for Jim His wife of 53 years, Sallie Lee Ricker Snow, valiantly fought and gracefullysuccumbed to cancer Sallie was exceptionally kind and thoughtful and engaged in our community She com-pleted Jim as a person, and her loss saddened all of us who knew her

mak-Looking at the first edition was amazing What were our predecessors thinking? What clinical challenges werethe greatest for them and how could they advance and develop the field? What was the world like a century ago?The 1908 Nobel Prize in Physiology or Medicine was given to Ilya Ilyich Mechnikov of Russia and PaulEhrlich of Germany in recognition of their work on immunity Other notable events that year include: thefirst time the ball signifying the New Year was dropped in Times Square, New York; General Baden-Powellfounded the Boy Scouts; Denmark, Germany, England, France, the Netherlands and Sweden signed theNorth Sea Accord; Mother’s Day was celebrated for the first time; the Lusitania crossed the Atlantic in arecord four days and 15 hours; Robert E Peary sailed from New York on his expedition to the North Pole;Bulgaria declared independence from the Ottoman Empire; Henry Ford introduced the Model T automo-bile; Albert Einstein presented his quantum theory of light; and, at age three, Hsuan-T’ung (Henry Pu-Yi)became the last Emperor of China Clearly much has changed in our world It is also true that much haschanged between the first and seventeenth editions of this book

Although a tremendous amount of work was completed during the two years that I spent with Jim in

designing and editing this book, I am proud to have played a role in this centennial edition of Ballenger’s Otorhinolaryngology Head and Neck Surgery I hope that all those using the printed book and its online ver-

sion will benefit from its organization and content; and, more importantly, I hope that a multitude ofpatients will benefit from the information contained in this edition

P Ashley Wackym, M.D

July 2008

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This centennial edition is dedicated to Sallie Lee Ricker Snow, wife, mother, artist, friend and colleague,whose keen intellect and faithful companionship served as the inspiration for this and several recenteditions

James B Snow, Jr., M.D

This work is dedicated to my wife Jeremy and my son Ashton from whom I have stolen innumerable hours in pursuit of the highest standard of academic otorhinolaryngology-head and neck surgery, and Paul Ward—the teacher who has influenced me the most

P Ashley Wackym, M.D

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Preface—James B Snow, Jr, MD vii Foreword—Richard A Chole, MD, PhD ix Introduction—P Ashley Wackym, MD xi

P Ashley Wackym, MD: Sectional Editor

1 Anatomy of the Auditory and Vestibular Systems

Richard R Gacek, MD 1

2 Development of the Ear

Daniel I Choo, MD, Gresham T Richter, MD 17

3 Molecular Biology of Hearing and Balance

Joni K Doherty, MD, PhD, Rick A Friedman, MD, PhD 29

4 Physiology of the Auditory and Vestibular Systems

Brenda L Lonsbury-Martin, PhD, Glen K Martin, PhD, Maureen T Hannley, PhD 45

5 Inner Ear Drug Delivery and Gene Therapy

Anil K Lalwani, MD, Nirmal P Patel, MD 81

6 Hair Cell Regeneration

Ricardo Cristobal, MD, PhD, Paul Popper, PhD, Fred A Pereira, PhD 89

7 Cochlear Biophysics

William E Brownell, PhD, John S Oghalai, MD 101

8 Central Auditory Processing and Functional Neuroimaging

Charles J Limb, MD, Marc D Eisen, MD, PhD 107

9 Diagnostic Audiology, Hearing Instruments and Aural Habilitation

James W Hall III, PhD, Kristin N Johnston, AuD 115

10 Evaluation of the Vestibular System

Joel A Goebel, MD, Judith A White, MD, PhD, Katherine D Heidenreich, MD 131

11 Imaging of the Temporal Bone

Mahmood F Mafee, M.D, Galdino E Valvassori, MD 145

12 Pathologic Correlates in Otology and Neurotology

Joseph B Nadol, Jr, MD 173

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13 Outcomes Research, Clinical Trials and Clinical Research

Maureen T Hannley, PhD, David L Witsell, MD, MHS 183

14 Diseases of the External Ear

Frank E Lucente, MD, Matthew Hanson, MD 191

15 Eustachian Tube Dysfunction

Dennis S Poe, MD, Quinton Gopen, MD 201

16 Otitis Media and Middle Ear Effusions

J Christopher Post, MD, PhD, Joseph E Kerschner, MD 209

17 Chronic Otitis Media and Cholesteatoma

Richard A Chole, MD, PhD, Robert Nason, MD 217

18 Cranial and Intracranial Complications of Acute and Chronic Otitis Media

David R Friedland, MD, PhD, Myles L Pensak, MD, John F Kveton, MD 229

19 Reconstruction of the Middle Ear

Saumil N Merchant, MD, John J Rosowski, PhD, Clough Shelton, MD 239

20 Otosclerosis

Herman A Jenkins, MD, Michael J McKenna, MD 247

21 Trauma to the Middle Ear, Inner Ear and Temporal Bone

D Bradley Welling, MD, PhD, Mark D Packer, MD 253

22 Noise-Induced Hearing Loss

Sharon G Kujawa, PhD 265

23 Ototoxicity

Peter S Roland, MD, Karen S Pawlowski, PhD 273

24 Idiopathic Sudden Sensorineural Hearing Loss

Robert Dobie, MD, Karen Jo Doyle, MD, PhD 279

25 Perilymphatic Fistulae

David R Friedland, MD, PhD 283

26 Hereditary Hearing Impairment

Richard J H Smith, MD, Amit Kochhar, BS, Rick A Friedman, MD, PhD 289

27 Autoimmune Inner Ear Disease and Other Autoimmune Diseases with Inner Ear Involvement

Jeffrey P Harris, MD, PhD, Quinton Gopen, MD, Elizabeth Keithley, PhD 305

28 Menière Disease, Vestibular Neuritis, Benign Paroxysmal Positional Vertigo, Superior Semicircular Canal

Dehiscence and Vestibular Migraine

David R Friedland, MD, PhD, Lloyd B Minor, MD 313

29 Presbyacusis and Presbyastasis

John H Mills, PhD, Cliff A Megerian, MD, Paul R Lambert, MD 333

30 Vestibular and Balance Rehabilitation

Susan L Whitney, PhD, PT, Joseph M Furman, MD, PhD 343

31 Tinnitus and Decreased Sound Tolerance

Pawel J Jastreboff, PhD, ScD, MBA, Margaret M Jastreboff, PhD 351

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Contents xv

32 Cochlear and Auditory Brainstem Implantation

P Ashley Wackym, MD, Christina L Runge-Samuelson, PhD 363

33 Cochlear Implant Coding Strategies and Device Programming

Kaibao Nie, PhD, Ward Drennan, PhD, Jay Rubinstein, MD PhD 389

34 Facial Paralysis

P Ashley Wackym, MD, John S Rhee, MD, MPH 395

35 Vestibular Schwannomas and Other Skull Base Neoplasms

Sumit K Agrawal, MD, Nikolas H Blevins, MD, Robert K Jackler, MD 413

36 Stereotactic Radiosurgery and Radiotherapy

P Ashley Wackym, MD, Christina L Runge-Samuelson, PhD, Linda Grossheim, MD 435

Andrew P Lane, MD: Sectional Editor

37 Embryology, Anatomy and Physiology of the Nose and Paranasal Sinuses

Peter H Hwang, MD, Arman Abdalkhani, MD 455

38 Olfaction and Gustation

Richard L Doty, PhD, Alexis H Jackman, MD 465

39 Cellular Biology of the Immune System

Bradley F Marple, MD, Raghu S Athré, MD 481

40 Assessment of Nasal Function

Jacquelynne P Corey, MD, Asli Sahin-Yilmaz, MD 493

41 Imaging of the Nasal Cavities, Paranasal Sinuses, Nasopharynx, Orbits,

Infratemporal Fossa, Pterygomaxillary Fissure and Base of Skull

Nafi Aygun, MD, David M Yousem, MD, MBA 501

42 Etiology of Infectious Diseases of the Upper Respiratory Tract

David M Poetker, MD, MA, Timothy L Smith, MD, MPH 519

43 Allergic Rhinitis

Robert M Naclerio, MD, Asli Sahin-Yilmaz, MD 531

44 Epistaxis

Thomas A Tami, MD, James A Merrell, MD 551

45 Acute and Chronic Nasal Disorders

Valerie J Lund, MS, FRCS, FRCS(Ed) 557

46 Acute Rhinosinusitis and Its Complications

Todd A Loehrl, MD, Timothy Wells, MD, Grant Su, MD 567

47 Chronic Rhinosinusitis and Polyposis

Rodney J Schlosser, MD, Bradford A Woodworth, MD 573

48 Headache and Facial Pain

James M Hartman, MD, Jeffrey W Yu, MD, Richard A Chole, MD, PhD 583

49 Primary Paranasal Sinus Surgery

James A Stankiewicz, MD, Joseph M Scianna, MD 595

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50 Revision Paranasal Sinus Surgery and Surgery of the Frontal Sinus

Andrew P Lane, MD, Marc G Dubin, MD 601

51 Endoscopic Surgery of the Skull Base, Orbits and Benign Sinonasal Neoplasms

Brent A Senior, MD, John Alldredge, MD 615

John S Rhee, MD, MPH: Sectional Editor

52 Otoplasty for the Prominent Ear

John S Rhee, MD, MPH, Jeffrey Tseng, MD 627

53 Rhinoplasty and Septoplasty

56 Wound Healing and Flap Physiology

John L Frodel, Jr, MD, Ian J Alexander, MD 699

57 Scar Revision and Skin Resurfacing

Theda C Kontis, MD 707

58 Local Flaps in Facial Reconstruction

Peter A Hilger, MD, Kofi O Boahene, MD 717

59 Regional Flaps and Free Tissue Transfer

Mark K Wax, MD, Shri Nadig, MD 727

60 Rejuvenation of the Upper Face and Midface

Theda C Kontis, MD, John S Rhee, MD, MPH 741

61 Rejuvenation of the Lower Face and Neck

Craig S Murakami, MD, Bryan T Ambro, MD, MS 749

J Christopher Post, MD, PhD: Sectional Editor

62 Microtia, Canal Atresia and Middle Ear Anomalies

Simon C Parisier, MD, Jose N Fayad, MD, Charles P Kimmelman, MD,Anthony P Sclafani, MD, George Alexiades, MD 759

63 Anatomy and Physiology of the Oral Cavity

Margaret A Kenna, MD, MPH, Manali Amin, MD 769

64 Diseases of the Oral Cavity, Oropharynx and Nasopharynx

Kenny H Chan, MD, Vijay R Ramakrishnan, MD 775

65 Deep Head and Neck Space Infections

Robert F Yellon, MD 783

66 Sleep Apnea in Children

Nira A Goldstein, MD 789

67 Robotic Surgery, Navigational Systems and Surgical Simulators

Todd A Loehrl, MD, Bert W O’Malley, Jr, MD, Gregory S Weinstein, MD, Aaron Sulman, MD 797

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Contents xvii

68 Airway Management in the Infant and Child

Michael J Rutter, MBChB, Robin T Cotton, MD 805

69 Congenital Anomalies of the Larynx

Rodney P Lusk, MD 815

70 Congenital Anomalies of the Head and Neck

Lee D Rowe, MD 829

71 Biofilms and Their Role in Ear and Respiratory Infections

J Chrisopher Post, MD, PhD, Garth D Ehrlich, PhD 839

Gayle E Woodson, MD: Sectional Editor

72 Development, Anatomy and Physiology of the Larynx

Clarence T Sasaki, MD, Young-Ho Kim, MD, PhD, Adam J LeVay, MD 847

73 Assessment of Vocal Function

Christine M Sapienza, PhD, Gayle E Woodson, MD 859

74 Disorders of Speech and Language

Raymond D Kent, PhD 867

75 Benign Laryngeal Lesions

Michael M Johns, MD, Shatul Parikh, MD 877

76 Laryngopharyngeal Reflux and Laryngeal Infections and Manifestations of Systemic Diseases

Kenneth W Altman, MD, PhD, Jamie A Koufman, MD 885

77 Trauma to the Larynx

Ricardo L Carrau, MD, Bridget C Hathaway, MD 899

78 Airway Control and Laryngotracheal Stenosis in Adults

Brian B Burkey, MD, Steven L Goudy, MD, Sarah L Rohde, MD 903

79 Neurogenic Disorders of the Larynx

Christy L Ludlow, PhD, Steven A Bielamowicz, MD 913

80 Laryngeal Paralysis

Lucian Sulica, MD 923

81 Muscle Misuse Disorders of the Larynx

Linda Rammage, PhD, Murray Morrison, MD, Hamish Nichol, MBChir 931

82 Imaging of the Larynx, Trachea and Esophagus

Albert L Merati, MD, Lacey Washington, MD 943

Gregory N Postma, MD, Melanie W Seybt, MD, Catherine J Rees, MD 975

86 Sleep Medicine and Surgery

B Tucker Woodson, MD 983

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▼ HEAD AND NECK SURGERY

Scott E Strome, MD: Sectional Editor

87 Molecular Biology of Squamous Cell Carcinoma

Carter Van Waes, MD, PhD 997

88 Mechanisms of Immune Evasion of Head and Neck Cancer

Brian R Gastman, MD, Aaron H D Wood, MD 1005

89 Molecular Diagnostic Approaches to Head and Neck Cancer

Ian M Smith, MD, Joseph A Califano, MD 1013

90 Imaging of the Oral Cavity, Pharynx, Salivary Glands and Neck

Robert E Morales, MD, Adam E Flanders, MD 1021

91 Targeted Therapeutic Approaches to Head and Neck Cancer

Stephen Y Lai, MD, PhD, Jennifer R Grandis, MD, PhD 1035

92 Chemoradiation for Head and Neck Cancer

Rob McCammon, MD, Changhu Chen, MD, Mohan Suntha, MD, David Raben, MD 1043

93 Immunotherapy for Head and Neck Cancer

Andrei I Chapoval, PhD, Dan H Schulze, PhD, Scott E Strome, MD 1055

94 Nutrition of the Patient with Head and Neck Cancer

Lawrence J DiNardo, MD, Elizabeth G Miller, RD 1063

95 Neoplasms of the Anterior Skull Base

Lawrence J Marentette, MD, Becky L Massey, MD, Robert M Kellman, MD 1071

96 Neoplasms of the Nasopharynx

Randall L Plant, MD 1081

97 Neoplasms of the Oral Cavity

Dennis H Kraus, MD, Mark G Shrime, MD 1091

98 Neoplasms of the Oropharynx and Hypopharynx

Douglas B Chepeha, MD, MPH, Theodoros N Teknos, MD, Amy Anne D Lassig, MD 1105

99 Neoplasms of the Larynx

Marshall Strome, MD, C Arturo Solares, MD 1121

100 Diseases of the Salivary Glands

Rodney J Taylor, MD, Jeffrey S Wolf, MD 1131

101 Management of Diseases of the Thyroid and Parathyroid Glands

Jan L Kasperbauer, MD, Bryan McIver, MB, PhD 1143

Index 1193

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Arman Abdalkhani, MD

Resident

Stanford University School of Medicine

Stanford, California

Embryology, Anatomy and Physiology of

the Nose and Paranasal Sinuses

Sumit K Agrawal, MD

Fellow (Otology/Neurotology)

Vestibular Schwannomas and Other

Skull Base Neoplasms

Ian J Alexander, MD

Fellow

Cosmetics Program

Facial Plastic Surgery and Otolaryngology

Geisinger Medical Center

Danville, Pennsylvania

Wound Healing and Flap Physiology

George Alexiades, MD

Associate Adjunct Professor

New York Eye and Ear Infirmary

New York, New York

Microtia, Canal Atresia and Middle

Ear Anomalies

John W Alldredge, MD

Resident

University of North Carolina at Chapel Hill

Chapel Hill, North Carolina

Endoscopic Surgery of the Skull Base, Orbits

and Benign Sinonasal Neoplasms

Kenneth W Altman, MD, PhD

Associate ProfessorDepartment of OtolaryngologyMount Sinai School of MedicineNew York, NY

Laryngopharyngeal Reflux and Laryngeal Infections and Manifestations of Systemic Diseases

Bryan T Ambro, MD, MS

Assistant ProfessorDivision of Facial Plastic and Reconstructive SurgeryDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Maryland Medical Center

Baltimore, Maryland

Rejuvenation of the Lower Face and Neck

Manali Amin, MD

Associate in OtolaryngologyDepartment of OtolaryngologyChildren’s Hospital of BostonBoston, Massachusetts

Anatomy and Physiology of the Oral Cavity

Raghu S Athré, MD

ResidentDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Texas Southwestern Medical Center at DallasDallas, Texas

Cellular Biology of the Immune System

Nafi Aygun, MD

Assistant ProfessorDivision of Neuroradiology Department of RadiologyJohns Hopkins University School of MedicineBaltimore, Maryland

Imaging of the Nasal Cavities, Paranasal Sinuses, Nasopharynx, Orbits, Infratemporal Fossa, Pterygomaxilliary Fissure and Base of Skull

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Shan R Baker, MD

Professor and Chief

The George Washington University

Washington, District of Columbia

Neurogenic Disorders of the Larynx

Nikolas H Blevins, MD

Associate Professor

Division of Otology and Neurotology

Kofi O Boahene, MD

Assistant Professor

Baltimore, Maryland

Local Flaps in Facial Reconstruction

William E Brownell, PhD

Jake and Nina Kamin Chair and Professor

Bobby R Alford Department of Otolaryngology–Head

and Neck Surgery

Baylor College of Medicine

Houston, Texas

Cochlear Biophysics

Brian B Burkey, MD

Associate Professor

Vice Chairman for Clinical Affairs and Education

Vanderbilt University Medical Center

Trauma to the Larynx

Kenny H Chan, MD

Professor and ChiefDivision of Pediatric OtolaryngologyDepartment of OtolaryngologyUniversity of Colorado Health Sciences CenterAurora, Colorado

Diseases of the Oral Cavity, Oropharynx and Nasopharynx

Andrei I Chapoval, PhD

Assistant Professor Department of Otorhinolaryngology–Head and Neck SurgeryUniversity of Maryland Medical Center

Baltimore, Maryland

Immunotherapy for Head and Neck Cancer

Changhu Chen, MD

Assistant ProfessorDivision of OncologyDepartment of Radiation OncologyUniversity of Colorado Health Sciences CenterAurora, Colorado

Chemoradiation for Head and Neck Cancer

Douglas B Chepeha, MD, MPH

Associate ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Michigan School of Medicine

Ann Arbor, Michigan

Neoplasms of the Oropharynx and Hypopharynx

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Chronic Otitis Media and Cholesteatoma

Headache and Facial Pain

Director, ENT Allergy Program

Section of Otolaryngology Head and Neck Surgery

Director, Otolaryngology–Head and Neck Surgery

Director, Aerodigestive Sleep Center

Department of Pediatric Otolaryngology

Cincinatti Children’s Hospital Medical Center

Cincinatti, Ohio

Airway Management in the Infant and Child

Mark S Courey, MD

Professor, Director, Division of Laryngology

Director, UCSF Voice Center

University of California at San Francisco

San Francisco, California

Rhinoplasty and Septoplasty

Laurence J DiNardo, MD

Professor and Vice ChairmanDepartment of Otolaryngology–Head and Neck SurgeryVirginia Commonwealth University Medical CenterRichmond, Virginia

Nutrition and the Patient with Head and Neck Cancer

Robert A Dobie, MD, FACS

Clinical ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of California Davis

Sacramento, California

Facial Fractures

Joni K Doherty, MD, PhD

Assistant Professor Division of Otolaryngology–Head and Neck SurgeryDepartment of Surgery

University of California at san DiegoSchool of Medicine

San Diego, California

Molecular Biology of Hearing and Balance

Richard L Doty, PhD

ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Pennsylvania School of Medicine

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Karen Jo Doyle, MD, PhD

Professor in Residence

University of California Davis

Kresge Hearing Research Institute

University of Michigan School of Medicine

Ann Arbor, Michigan

Cochlear Implant Coding Strategies

and Device Programming

Marc G Dubin, MD, FACS

Assistant Professor

Baltimore, Maryland

Revision Paranasal Sinus Surgery and

Surgery of the Frontal Sinus

Garth D Ehrlich, PhD

Professor of Microbiology,

Immunology and Otolaryngology

Professor and Vice Chairman, Human Genetics

Executive Director

Department of Internal Medicine

University of Utah School of Medicine

Salt Lake City, Utah

Bronchology

Jose N Fayad, MD

AssociateHouse ClinicHouse Ear InstituteLos Angeles, California

Microtia, Canal Atresia and Middle Ear Anomalies

Adam E Flanders, MD

Consultant/NeuroradiologyProfessor of Rehabilitation MedicineDivision of Neuroradiology/ENTDepartment of RadiologyThomas Jefferson University Medical CollegePhiladelphia, Pennsylvania

Imaging of the Oral Cavity, Pharynx, Salivary Glands and Neck

David R Friedland, MD, PhD

Associate Professor and ChiefDivision of Otology and Neuro-Otologic Skull Base SurgeryDepartment of Otolaryngology and

Communication SciencesMedical College of WisconsinMilwaukee, Wisconsin

Cranial and Intracranial Complications

of Acute and Chronic Otitis Media Menière Disease, Vestibular Neuritis, Benign Paroxyysmal Positional Vertigo, Superior Semicircular Canal Dehiscence and Vestibular Migraine

Perilymphatic Fistulae

Rick A Friedman, MD, PhD

Neurotologist, House Ear ClinicChief, Section on Hereditary Disorders of the Ear House Ear Institute

Los Angeles, California

Hereditary Hearing Impairment Molecular Biology of Hearing and Balance

John L Frodel Jr, MD

Director, Cosmetics ProgramFacial Plastic Surgery and OtolaryngologyGeisinger Medical Center

Danville, Pennsylvania

Wound Healing and Flap Physiology

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University of Massachusetts Medical Center

Worcester, Massachusetts

Anatomy of the Auditory and Vestibular Systems

Brian R Gastman, MD

Assistant Professor

Division of Facial Plastic Surgery

Department of Otorhinolaryngology–Head and Neck Surgery

University of Maryland Medical Center

Baltimore, Maryland

Mechanisms of Immune Evasion of

Head and Neck Cancer

Joel A Goebel, MD, FACS

Professor and Vice Chairman

Washington University School of Medicine

State University of New York

Downstate Medical Center

Brooklyn, New York

Sleep Apnea in Children

Autoimmune Inner Ear Disease and

Other Autoimmune Diseases with

Inner Ear Involvement

Eustachian Tube Dysfunction

Jennifer R Grandis, MD, PhD, FACS

Professor and Vice Chair for ResearchDepartment of OtolaryngologyUniversity of Pittsburgh School of MedicinePittsburgh, Pennsylvania

Targeted Therapeutic Approaches to Head and Neck Cancer

Linda Grossheim, MD

Assistant Professor Department of Radiation OncologyMedical College of WisconsinMilwaukee, Wisconsin

Stereotactic Radiosurgery and Radiotherapy

James W Hall III, PhD

Clinical Professor and Associate ChairDepartment of Communicative DisordersUniversity of Florida

Diseases of the External Ear

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Jeffrey P Harris, MD, PhD, FACS

Professor and Chief

Division of Otolaryngology–Head and Neck Surgery

Department of Surgery

University of California at San Diego

Autoimmune Inner Ear Disease and Other

Autoimmune Diseases with Inner Ear Involvement

James M Hartman, MD

Town and Country Head and Neck

Saint Louis, Missouri

Head/Neck Surgery Lions 5M

International Hearing Center

Director, Stanford Sinus Center

Embryology, Anatomy and Physiology

of the Nose and Paranasal Sinuses

Robert K Jackler, MD

Sewall Professor and Chair

Stanford University

Alexis H Jackman, MD

Assistant ProfessorDepartment of Otolaryngology–Head and Neck SurgeryAlbert Einstein College of Medicine

Montefiore Medical CenterBronx, New York

Olfaction and Gustation

Margaret M Jastreboff, PhD

Visiting Research ProfessorDepartment of Audiology, Speech-LanguagePathology and Deaf Studies

Towson UniversityTowson, Maryland

Tinnitus and Decreased Sound Tolerance

Pawel J Jastreboff, PhD, ScD, MBA

ProfessorDepartment of OtolaryngologyEmory University

Denver, Colorado

Otosclerosis

Michael M Johns, MD

Assistant ProfessorDirector, Emory Voice CenterDepartment of OtolaryngologyEmory University School of MedicineAtlanta, Georgia

Benign Laryngeal Lesions

Kristin N Johnston, AuD

InstructorDepartment of Communicative DisordersUniversity of Florida

Gainesville, Florida

Diagnostic Audiology, Hearing Instruments and Aural Habilitation

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University of California at San Diego

Autoimmune Inner Ear Disease and Other

Autoimmune Diseases with Inner Ear Involvement

Robert M Kellman, MD

Professor and Chair

Department of Otolaryngology and

Communication Sciences

SUNY Upstate Medical Center

Syracuse, New York

Neoplasms of the Anterior Skull Base

Margaret A Kenna, MD, MPH

Associate Professor of Otology

and Laryngology

Department of Otolaryngology

Harvard Medical School

Children’s Hospital, Boston

Professor and Chief

Division of Pediatric Otolaryngology

Academic Vice Chairman

993 Park AvenueNew York, New York

Amit Kochhar, BS

FellowDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Iowa Carver College of Medicine

Iowa City, Iowa

Hereditary Hearing Impairment

Theda C Kontis, MD

Facial Plastic Surgicenter, Ltd

1838 Greene Tea RoadBaltimore, Maryland

Rejuvenation of the Upper Face and Midface

Scar Revision and Skin Resurfacing

Neoplasms of the Oral Cavity

Sharon G Kujawa, PhD

Associate ProfessorDepartment of Otology and LaryngologyHarvard Medical School

Boston, Massachusetts

Noise-Induced Hearing Loss

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John F Kveton, MD

46 Prince Street

New Haven, Connecticut

Cranial and Intracranial Complications

of Acute and Chronic Otitis Media

Targeted Therapeutic Approaches to

Anil K Lalwani, MD

Mendik Foundation Professor and Chairman

New York University Medical Center

New York, New York

Inner Ear Drug Delivery and Gene Therapy

Paul R Lambert, MD

Professor and Chair

Medical University of South Carolina

Charleston, South Carolina

Presbyacusis and Presbyastasis

Andrew P Lane, MD

Director of Rhinology and Sinus Surgery

Baltimore, Maryland

Revision Paranasal Sinus Surgery and

Surgery of the Frontal Sinus

Adam J LeVay, MD

Resident

Section of Otolaryngology

Yale University School of Medicine

Development, Anatomy and Physiology of the Larynx

Amy Anne Donatelli Lassig, MD

Assistant ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Minnesota Medical School

Minneapolis, Minnesota

Charles J Limb, MD

Assistant ProfessorDepartment of Otolaryngology–Head and Neck SurgeryJohns Hopkins University School of Medicine

Medical College of WisconsinMilwaukee, Wisconsin

Acute Rhinosinusitis and its Complications Robotic Surgery, Navigational Systems and Surgical Simulators

Brenda L Lonsbury-Martin, PhD

ProfessorDepartment of Otolaryngology–Head and Neck SurgeryLoma Linda University

Loma Linda, California

Physiology of the Auditory and Vestibular Systems

Frank E Lucente, MD

Professor and ChairmanDepartment of OtolaryngologyState University of New YorkDownstate Medical CenterBrooklyn, New York

Diseases of the External Ear

Christy L Ludlow, PhD

Senior InvestigatorLaryngeal and Speech SectionClinical Neuroscience ProgramNational Institute of Neurological Disorders and StrokeBethesda, Maryland

Neurogenic Disorders of the Larynx

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Valerie J Lund, MS, FRCS, FRCS(Ed)

Boys Town Ear, Nose and Throat Institute

Boys Town National Research Hospital

Director of the Cochlear Implant Center

University of California, San Diego School of Medicine

Imaging of the Temporal Bone

Lawrence J Marentette, MD

Professor

Departments of Neurosurgery and Otolaryngology

University of Michigan Health System

Ann Arbor, Michigan

Bradley F Marple, MD

Professor and Vice Chairman

University of Texas Southwestern Medical School

Dallas, Texas

Cellular Biology of the Immune System

Glen K Martin, PhD

Professor

Loma Linda University

Loma Linda, California

Physiology of the Auditory and Vestibular Systems

Becky L Massey, MD

Assistant ProfessorDivision of Head and Neck OncologyDepartment of Otolaryngology and Communication Sciences

Rob McCammon, MD

Resident PhysicianDivision of OncologyDepartment of Radiation OncologyUniversity of Colorado Health Sciences CenterAurora, Colorado

Bryan McIver, MB, PhD

Fellow in EndocrinologyThe Mayo Clinic

Cleveland, Ohio

Albert L Merati, MD

Associate ProfessorChief of the Division of LaryngologyDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Washington

School of MedicineSeattle, Washington

Imaging of the Larynx, Trachea and Esophagus

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Saumil N Merchant, MD

Gudren Larsen Eliasen and Nels Kristian Eliasen

Professor of Otology and Laryngology

Department of Otology and Laryngology

Reconstruction of the Middle Ear

James A Merrell, MD

Resident

University of Cincinnati College of Medicine

Nutrition of the Patient with

John H Mills, PhD

Professor

Lloyd B Minor, MD

Andelot Professor and Director

Baltimore, Maryland

Menière Disease, Vestibular Neuritis, Benign

Paroxysmal Positional Vertigo, Superior

Semicircular Canal Dehiscence and

Imaging of the Oral Cavity, Pharynx,

Salivary Glands and Neck

Murray D Morrison, MD, FRCSC

ProfessorDivision of OtolaryngologyDepartment of SurgeryUniversity of British ColumbiaVancouver, British Columbia

Muscle Misuse Disorders of the Larynx

Craig S Murakami, MD

Clinical Associate ProfessorDivision of Facial Plastic and Reconstructive SurgeryDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Washington

University of Chicago Medical CenterChicago, Illinois

Allergic Rhinitis

Shri Nadig, MD

LecturerDepartment of Otolaryngology–Head and Neck SurgeryOregon Health & Science University

Pathologic Correlates in Otology and Neurotology

Robert Nason, MD

ResidentDepartment of OtolaryngologyWashington University School of Medicine

St Louis, Missouri

Chronic Otitis Media and Cholesteatoma

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Hamish Nichol, MBChir

Professor Emeritus

Department of Psychiatry

University of British Columbia

Vancouver, British Columbia

Muscle Misuse Disorders of the Pharynx

Cochlear Implant Coding Strategies

and Device Programming

Gabriel Tucker Professor and Chair

University of Pennsylvania Health System

Philadelphia, Pennsylvania

Robotic Surgery, Navigational Systems

and Surgical Simulators

Mark D Packer, MD

Neurotology Fellow

Division of Neurotology

Ohio State University

Columbus, Ohio

Trauma to the Middle Ear, Inner, Ear and Temporal Bone

Shatul Parikh, MD

Resident

Emory University School of Medicine

Atlanta, Georgia

Benign Laryngeal Lesions

Simon C Parisier, MD

Co-DirectorOtolaryngology, Head and Neck SurgeryNew York Eye and Ear Infirmary

New York, New York

Nirmal P Patel, MD

Garnett Passe Research FellowDepartment of OtolaryngologyNew York University School of MedicineNew York, New York

Inner Ear Drug Delivery and Gene Therapy

Karen S Pawlowski, PhD

Assistant ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Texas

Southwestern Medical Center at DallasDallas, Texas

Ototoxicity

Myles L Pensak, MD

H.B Brody Professor and ChairmanDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Cincinnati College of Medicine

Huffington Center on AgingBaylor College of MedicineHouston, Texas

Hair Cell Regeneration

Randall L Plant, MD

Department of OtolaryngologyAlaska Native Medical CenterAnchorage, Alaska

Neoplasms of the Nasopharynx

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Hair Cell Regeneration

J Christopher Post, MD, PhD, FACS

Professor of Otolaryngology,

Microbiology and Immunology

President and Scientific Director

Biofilms and Their Role in Ear and Respiratory Infections

Otitis Media and Middle Ear Effusions

Gregory N Postma, MD

Professor and Director

Center for Voice and Swallowing Disorders

Endoscopic Surgery of the Skull Base, Orbits, and Benign Sinonasal Neoplasms

Health Sciences CenterAurora, Colorado

Vijay R Ramakrishnan, MD

Staff PhysicianDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Colorado Health Sciences Center

Muscle Misuse Disorders of the Larynx

John S Rhee, MD, MPH

Associate Professor and ChiefDivision of Facial Plastic and Reconstructive SurgeryDepartment of Otolaryngology and Communication SciencesMedical College of Wisconsin

Facial Paralysis Ostoplasty of the Prominent Ear Rejuvenation of the Upper Face and Midface

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Catherine J Rees, MD

Assistant Professor and Medical Director

Center for Voice and Swallowing Disorders

Wake Forest University Baptist Medical Center

Winston-Salem, North Carolina

Esophagology

Gresham T Richter, MD

Assistant Professor

University of Arkansas for Medical Sciences

Little Rock, Arkansas

Development of the Ear

Frederick C Roediger, MD

Resident

University of California at San Francisco

San Francisco, California

Laryngoscopy

Sarah L Rohde, MD

Resident

Vanderbilt University Medical Center

Nashville, Tennessee

Airway Control and Laryngotracheal

Stenosis in Adults

Peter S Roland, MD

Professor and Chairman

Department of Otology and Laryngology

Lee D Rowe, MD

Associate Clinical Professor

Thomas Jefferson University Medical College

Cochlear and Auditory Brainstem Implantation Stereotactic Radiosurgery and Radiotherapy

Michael J Rutter, MBChB

Associate ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Cincinnati College of Medicine

Director of Clinical ResearchChildren’s Hospital of CincinnatiCincinnati, Ohio

Airway Management in the Infant and Child

Asli Sahin-Yilmaz, MD

FellowSection of OtolaryngologyDepartment of SurgeryUniversity of ChicagoChicago, Illinois

Allergic Rhinitis Assessment of Nasal Function

Christine M Sapienza, PhD

Professor and ChairDepartment of Communication Sciences and DisordersUniversity of Florida

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Clarence T Sasaki, MD

Charles W Ohse Professor and Chief

Section of Otolaryngology

Yale University School of Medicine

Development, Anatomy and Physiology

of the Larynx

Rodney J Schlosser, MD

Assistant Professor and Director,

Chronic Rhinosinusitis and Polyposis

Dan H Schulze, PhD

Associate Professor

Department of Microbiology and Immunology

University of Marlyand School of Medicine

Professor and Director of Facial Plastic Surgery

The New York Eye and Ear Infirmary

New York, New York

Microtia, Canal Atresia and

Middle Ear Atresia

Brent A Senior, MD, FACS, FARS

Associate Professor

Division of Rhinology, Allergy and Sinus Surgery

University of North Carolina at Chapel Hill

Chapel Hill, North Carolina

Endoscopic Surgery of the Skull Base,

Orbits and Benign Sinonasal Neoplasms

Melanie W Seybt, MD

ResidentDepartment of Otolaryngology–Head and Neck SurgeryMedical College of Georgia

University of UtahSalt Lake City, Utah

Mark G Shrime, MD

FellowDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Toronto

Toronto, Ontario, Canada

Neoplasms of the Oral Cavity

Ian M Smith, MD

ResidentDepartment of Otolaryngology–Head and Neck SurgeryJohns Hopkins University School of Medicine

Baltimore, Maryland

Molecular Diagnostic Approaches to Head and Neck Cancer

Marshall E Smith, MD

Associate ProfessorDivision of Otolaryngology–Head and Neck SurgeryDepartment of Surgery

University of UtahSalt Lake City, Utah

Bronchology

Richard J H Smith, MD

Professor and Vice ChairmanDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Iowa Health Care

Iowa City, Iowa

Hereditary Hearing Impairment

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Professor and Chairman

Loyola Medical Center

Maywood, Illinois

Primary Paranasal Sinus Surgery

Marshall Strome, MD, MS

Director Center for Head and Neck Oncology

Co-Director Head and Neck Transplantation Program,

Center for Facial Reconstruction

St Luke’s–Roosevelt Hospital Centers

New York, New York

Neoplasms of the Larynx

Scott E Strome, MD, FACS

Professor and Chair

University of Maryland Medical Center

Weill Cornell Medical College

New York, New York

Laryngeal Paralysis

Aaron Sulman, MD

Assistant ProfessorDepartment of UrologyMedical College of WisconsinMilwaukee, Wisconsin

Robotic Surgery, Navigational Systems and Surgical Simulators

Mohan Suntha, MD

ProfessorDivision of OncologyDepartment of Radiation OncologyUniversity of Maryland School of MedicineBaltimore, Maryland

Thomas A Tami, MD

Professor Department of OtolaryngologyUniversity of Cincinnati College of MedicineCincinnati, Ohio

Epistaxis

Rodney J Taylor, MD

Assistant ProfessorDivision of General OtolaryngologyDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Maryland School of Medicine

Baltimore, Maryland

Diseases of the Salivary Glands

Theodoros N Teknos, MD

Associate ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Michigan, Medical School

Ann Arbor, Michigan

Jeffrey Tseng, MD

ResidentDepartment of Otolaryngology and Communication SciencesMedical College of Wisconsin

Ostoplasty of the Prominent Ear

Galdino E Valvassori, MD

ProfessorDepartment of RadiologyUniversity of Illinois, ChicagoChicago, Illinois

Imaging of the Temporal Bone

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P Ashley Wackym, MD, FACS, FAAP

John C Koss Professor and Chairman

Stereotactic Radiosurgery and Radiotherapy

Carter Van Waes, MD, PhD

Chief, Head and Neck Surgery Branch

Durham, North Carolina

Imaging of the Larynx, Trachea

and Esophagus

Mark K Wax, MD

Professor

Oregon Health & Science University

Portland, Oregon

Regional Flaps and Free Tissue Transfer

Gregory S Weinstein, MD

Professor and Vice-Chairman

Director, Division of Head and Neck Surgery

Department of Otorhinolaryngology–Head and Neck Surgery

University of Pennsylvania

Philadelphia, Pennsylvania

Robotic Surgery, Navigational Systems

and Surgical Simulators

D Bradley Welling, MD, PhD

Professor and Chair

Ohio State University

Columbus, Ohio

Trauma to the Middle Ear, Inner Ear and Temporal Bone

Timothy S Wells, MD

Assistant ProfessorDepartment of OphthalmologyMedical College of WisconsinMilwaukee, Wisconsin

Acute Rhinosinusitis and Its Complications

Judith A White, MD, PhD

Section Head, Vestibular and Balance DisordersHead and Neck Institute

Cleveland ClinicCleveland, Ohio

Evaluation of the Vestibular System

Susan L Whitney, PhD, PT, NCS, FAPTA

Associate ProfessorDepartments of Physical Therapy and Otolaryngology

University of Pittsburgh School of MedicinePittsburgh, Pennsylvania

Vestibular and Balance Rehabilitation

David L Witsell, MD, MHS

Associate ProfessorDivision of Otolaryngology–Head and Neck SurgeryDepartment of Surgery

Duke University Medical CenterDurham, North Carolina

Outcomes Research, Clinical Trials and Clinical Research

Jeffrey S Wolf, MD, FACS

Assistant ProfessorDepartment of Otolaryngology–Head and Neck SurgeryUniversity of Maryland School of Medicine

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Gayle E Woodson, MD

Professor and Chief

Division of Otolaryngology–Head and Neck Surgery

Southern Illinois University

Springfield, Illinois

Assessment of Vocal Function

B Tucker Woodson, MD, DABSM

Professor and Chief

Division of Sleep Medicine

Associate Professor, Co-Director and Co-Chief

Division of Pediatric Otolaryngology

Children’s Hospital of Pittsburgh

University of Pittsburgh School of Medicine

Deep Head and Neck Space Infections

David M Yousem, MD, MBA

Professor of RadiologyDirector of NeuroradiologyDivision of NeuroradiologyDepartment of RadiologyJohns Hopkins University School of MedicineBaltimore, Maryland

Imaging of the Nasal Cavities, Paranasal Sinuses, Nasopharynx, Orbits, Infratemporal Fossa, Pterygomaxillary Fissure and Base of Skull

Jeffrey W Yu, MD

Research FellowDepartment of OtolaryngologyWashington University School of Medicine

St Louis, Missouri

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The temporal bone (TB) is a complex portion

of the skull base that contains the labyrinth with

its nerve supply (cranial nerve VIII) and also

other cranial nerves such as the facial,

trigemi-nal, vagus, glossopharyngeal, spinal accessory,

and hypoglossal nerves A thorough

knowl-edge of the gross and microscopic anatomy1,2

of the TB and the physiology of the

labyrin-thine sense organs is essential for the specialist

who strives for accuracy in diagnosis and

preci-sion in surgery of the TB This knowledge is

gained fi rst from dissection of cadaveric whole

TB specimens but is greatly enhanced by study

of prepared histologic sections from normal and

pathologic TB

OSTEOLOGY

Four major components of the TB contribute to the skull base: the squamous, tympanic, mastoid, and petrous

The squamous portion of the TB provides

attachment for the temporalis muscle, which is bounded inferiorly by the temporal line (Figure 1)

The temporal line provides an external landmark for the fl oor of the middle cranial fossa The zygo-matic process projects forward from the lower portion of this bone, and together they form the anterior border of the mandibular fossa, which receives the condyle of the mandible

The tympanic portion of the TB is an

incom-plete cylindrical portion of the TB that, together

with the squamosal portion, forms the medial part

of the external auditory canal This portion of the external auditory canal is 2 cm in length by 1 cm

in diameter Its anterior boundary is the posterior limit of the mandibular fossa; medially, its bor-der is the tympanic membrane The posterior part fuses with the mastoid component of the TB at the tympanomastoid suture Failure in develop-ment of this part of the TB is responsible for con-genital aural atresia, a form of conductive hearing loss correctable by surgery

The major portion of the TB formed by the

mastoid portion attributes its large size to

exten-sive pneumatization The mastoid process ects posteriorly and inferiorly behind the external auditory meatus and serves as the attachment for the sternocleidomastoid muscle A deep groove

proj-in its proj-inferior aspect houses the posterior belly of the digastric muscle, which is innervated by the facial nerve The superior surface of the mastoid compartment is formed by a thin plate of bone known as the tegmen mastoidea Posteriorly, it forms the anterior plate of the posterior cranial fossa and is indented by a groove for the sigmoid sinus The superior and inferior petrosal sinuses travel medially along the superior and inferior aspects of this part of the TB

The petrous portion of the TB forms its medial

part inferior to the middle cranial fossa; orly, it forms the anterior surface of the posterior cranial fossa (Figure 2) The superior surface of the petrous bone is highlighted by the prominence

posteri-of the superior semicircular canal, a landmark in surgery within the middle cranial fossa Anterior

to this portion of the petrous bone is the hiatus for the greater superfi cial petrosal nerve, which joins with the geniculate ganglion of the facial nerve

In some temporal bones, this hiatus is enlarged, and the geniculate ganglion may be exposed in the middle cranial fossa Anterior and medial to this region is a concave area for the semilunar ganglion of the trigeminal nerve On the posterior surface of the petrous bone are several impor-tant landmarks The most obvious aperture is the

OTOLOGY AND NEUROTOLOGY

Anatomy of the Auditory and Vestibular Systems

Richard R Gacek, MD

1

Figure 1 Right temporal bone, lateral view (Reproduced with permission from reference 2.)

▼

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2 PART I / Otology and Neurotology

internal auditory meatus (canal) that transmits the

seventh and eighth cranial nerves as well as the

labyrinthine artery or loop of the anterior

infe-rior cerebellar artery (Figure 3) The lateral end

(fundus) of the internal auditory canal (IAC) is

divided horizontally by the falciform crest.1,2 The

superior compartment contains the facial nerve

anteriorly and the superior division of the

ves-tibular nerve posteriorly (Figure 4) The inferior

compartment transmits the cochlear nerve

ante-riorly and the inferior division of the vestibular

nerve posteriorly The endolymphatic sac may

be found in a depression covered by a bony shelf

(operculum) anterior to the sigmoid groove It

narrows down into the vestibular aqueduct as the

intraosseous endolymphatic sac The depression

for the semilunar ganglion and the fi fth cranial

nerve on the anterior surface of the petrous bone

also carries the sixth cranial nerve through a

dural canal referred to as Dorello’s canal These

two nerves may be involved in infl ammatory

or neoplastic processes that occupy the petrous

apex (PA) and are responsible for the clinical

syndrome known as Gradenigo syndrome (fi fth

cranial nerve pain, diplopia from lateral rectus

muscle palsy, and otorrhea)

AUDITORY SYSTEM External Ear

The external or outer ear is that portion of the ear that is lateral to the tympanic membrane (Figure 5).3 It consists of the external auditory canal as well as the auricle and cartilaginous por-tion of the ear

The auricle is a semicircular plate of elastic cartilage characterized by a number of ridges or grooves The major ridges of the auricle are the helix and antihelix, the tragus and antitragus, which surround the concha, which is the scaph-oid depression posterior to the external auditory meatus The cartilage of the external auditory meatus is continuous with that of the outer por-tion of the ear canal and auricle

The external auditory canal is made up of a cartilaginous extension of the auricle in its outer half and the mastoid and tympanic portion of the

TB in its medial half It is bounded medially by the tympanic membrane and is lined with skin that is thin with little subcutaneous tissue medi-ally but laterally contains numerous hair follicles and ceruminous and sebaceous glands The bony external auditory canal averages 3.5 cm in length, with a diameter of 1 cm The tympanic membrane

is composed of three layers: the outer squamous cell epithelial layer, the medial mucosal layer fac-ing the middle ear, and the fi brous layer or tunica propria, forming the substance of the tympanic membrane.4 The fi brous layer gives the tympanic membrane its shape and consistency Radial

fi bers of the tunica propria insert into the brium, circumferential fi bers providing strength without interfering with vibration, whereas tan-gential fi bers reinforce the architecture of the tympanic membrane These physical characteris-tics are important for the vibratory characteristics necessary for sound transmission

manu-The tympanic membrane is identifi ed by

a prominent landmark, the manubrium of the

S L U

V F

SA

P

B

Figure 4 Human inner ear dissection with nerve supply

demonstrates the relationship of the facial (F) and superior vestibular nerve (V) in the superior compartment of the internal canal B ⫽ basal turn of cochlea; GSP ⫽ greater superfi cial petrosal nerve; G ⫽ geniculate ganglion; L ⫽ lateral canal crista; P ⫽ posterior canal crista; S ⫽ superior canal crista; SA ⫽ saccule; U ⫽ utricle.

Figure 3 This orientation of the human inner ear

dissec-tion shows the anatomical reladissec-tionship of the nerves and

sense organs when viewed from the posterior surface of

the temporal bone IAM ⫽ internal auditory meatus; V

⫽ vestibular nerve trunk; C ⫽ cochlear nerve trunk; F ⫽

facial nerve; BC ⫽ basal turn of cochlea; SA ⫽ saccule; U

⫽ utricular nerve; S, L, P ⫽ superior, lateral, and posterior

semicircular canal ampullae; * ⫽ cleavage plane between

vestibular and cochlear nerve trunks. Figure 5 General relationship of parts of the ear (semidiagrammatic) (Reproduced with permission from reference 3.)

Figure 2 Left temporal bone,

pos-terolateral view (Reproduced with permission from reference 2.)

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CHAPTER 1 / Anatomy of the Auditory and Vestibular Systems 3

malleus, which is limited superiorly by its lateral

or short process and inferiorly by a rounded end

referred to as the umbo (Figure 6) The umbo

forms the deep apex of the conical shape formed

by the tympanic membrane The tympanic

mem-brane is incomplete superiorly, where it lacks a

fi brous layer in the portion superior to the short

process of the manubrium.5 Since it lacks a

fi brous layer, this portion is called the pars fl

ac-cida (Shrapnell’s membrane) The major or

infe-rior portion of the tympanic membrane is referred

to as the pars tensa

Middle Ear

The space between the tympanic membrane and

the bony capsule of the labyrinth in the petrous

portion of the TB contains the ossicular chain

with its associated muscles, the aperture of the

eustachian tube, and the vascular system The

tympanic cavity is divided into the epitympanic,

mesotympanic, and hypotympanic regions The

hypotympanic portion is that portion of the middle

ear that lies inferior to the aperture of the

eusta-chian tube and the round window niche (RWN)

This portion of the middle ear contains various

bony trabeculae and the bony covering of the

jug-ular bulb This bony surface may be dehiscent,

exposing the jugular bulb in the hypotympanic

region Inferiorly, a small channel (the inferior

tympanic canaliculus) transmits Jacobson nerve

(a branch of cranial nerve IX)

The mesotympanic portion of the middle

ear is limited superiorly by the horizontal

por-tion of the facial canal and inferiorly by the

RWN This region contains the oval and round

windows, the stapes bone, the stapedius muscle

posteriorly, and the canal for the tensor tympani

muscle anteriorly The oval window is kidney

bean shaped with a convex superior rim and a

concave inferior rim In the oval window, the

footplate of the stapes bone is held in place by

the annular ligament The RWN forms a deep

recess often covered with various mucous

mem-brane confi gurations that obscure the round

win-dow membrane (RWM) The RWM is a fi brous

membrane covered with a layer of mucosa that is roughly kidney bean shaped, with a major com-ponent anterior and inferior and a minor compo-nent located posteriorly and horizontally in the RWN Posteriorly, in the mesotympanum there are two bony recesses of clinical importance

The recess lateral to the vertical segment of the facial canal is called the facial recess The space medial to the facial canal is called the sinus tym-pani (Figure 7) These two recesses are important clinically as they frequently harbor chronic mid-dle ear infection and must be controlled in sur-gery The facial recess also provides access to the middle ear space and RWN in those procedures

in which the ear canal wall is preserved (ie, intact canal wall mastoidectomy, cochlear implanta-tion) A bony projection from the facial canal (pyramidal eminence) contains the tendon of the stapedius muscle before its insertion into the neck

of the stapes bone The most anterior portion of

the middle ear space is called the protympanum

and is bordered superiorly by the orifi ce of the eustachian tube and anteriorly by the canal for the internal carotid artery (see Figure 7)

The epitympanum is the portion of the

mid-dle ear that is limited superiorly by the bony roof of the middle ear called the tegmen tym-pani This bony landmark is continuous pos-teriorly as the tegmen mastoidea The medial wall of the epitympanum is formed by the bony prominence of the lateral and superior semicir-cular canal ampullae as well as the epitympanic portion of the facial (fallopian) canal The head and neck of the malleus and its articulation with the body and short process and a portion of the long process of the incus occupy most of the space in the epitympanum These two ossicular masses are held in place by ligaments anteriorly and posteriorly to provide an axis of rotation for the ossicular chain (Figure 8) The epitym-panic space communicates posteriorly through

a narrow opening called the aditus ad antrum to the central mastoid tract of the mastoid cavity

Anteriorly, the epitympanum is separated at the cochleariform process from an anterior epitym-panic cell of variable size by a bony and mucous membrane barrier, which may completely or incompletely separate the two compartments This anterior epitympanic space is formed by pneumatization from the protympanum (see Figure 8) The anterior epitympanic space is also important surgically as it may contain infl amma-tory tissue (ie, cholesteatoma) that has extended from the protympanum

Auditory Ossicles Sound pressure energy is

transmitted from the tympanic membrane across the middle ear space by the ossicular chain com-posed of the malleus, incus, and stapes (Figure 9).6The head of the malleus and body of the incus function as a unit suspended by ligaments in the epitympanum The tip of the long process of the incus articulates at a right angle with the head of the stapes so that the sound energy transmission initiated by medial displacement of the tympanic membrane is carried by the parallel displacement

of the elongate processes of the malleus and incus

to the head, crura, and footplate of the stapes (see Figure 9) Since the surface area of the tympanic membrane is larger than that of the stapes footplate

by a ratio of 25 to 1, the sound pressure density in the oval window and the inner ear fl uids is simi-larly increased Maintaining this ratio by various reconstructive methods constitutes an important principle in middle ear surgery The stapes there-fore acts in a piston-like fashion in the oval win-dow The stapes bone is shaped like a stirrup with

a head, neck, and footplate or base The crura are bowed, the posterior one more so than the anterior, and fused with the footplate, which is formed from both otic capsule and periosteal bone These audi-tory ossicles are controlled to some degree by two middle ear muscles, the tensor tympani and the stapedius The tensor tympani muscle is housed in

a bony semicanal in the anterior mesotympanum

Figure 7 This axial computed tomographic scan of the

temporal bone illustrates a normal mastoid cell system (MA), the horizontal segment of the internal carotid artery (ICA), the jugular bulb (JB), the sigmoid sinus (SS), and a nonpneumatized petrous apex (PA) C ⫽ basal turn of the cochlea; FN ⫽ facial nerve; T ⫽ sinus tympani.

Figure 8 This horizontal cut through a

celloidin-embedded temporal bone illustrates the relationship of the facial nerve (FN) to the superior division of the vestibular nerve (VN) in the internal auditory canal The axis of rotation of the head of the malleus (M) and body of the incus (I) with their ligamentous attachments in the epitympanum

is shown AE ⫽ anterior epitympanic space ventilated into the protympanum (*); LC ⫽ lateral semicircular canal crista and ampulla; PC ⫽ posterior semicircular canal;

C ⫽ endosteum of the cochlea (basal turn); TT ⫽ tensor tympani tendon; G ⫽ geniculate ganglion.

I M

Figure 6 Photograph of a normal left tympanic

mem-brane I ⫽ long process of incus; M ⫽ malleus; R ⫽ round

window niche; U ⫽ umbo.

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