PEDIATRIC OTOLOGIC

SURGERY
 I. ACOUSTICS
• SOUND- energy waves of particle displacement
• The velocity of sound propagation:
• Dry air- 340 m/sec at room temperature
• Water- 1500 m/sec

• FREQUENCY- number of cycles per second

• measured in Hertz (Hz)
• Human ear capable of hearing from approximately 20 to 20,000 Hz.
 PERIOD
SIMPLE HARMONIC MOTION • represents the
duration of a
single cycle;
• inverse of its
frequency (1/f)

AMPLITUDE
• Max. amount of
displacement
from the null
point in one
direction
• Measured in
Decibels

PURE TONE- sound produced by simple harmonic motion

 I. ACOUSTICS
• COMPLEX TONE- any vibration that does not follow simple harmonic motion
• sound comprising more than one frequency

• TONE- complex vibration has a repetitive periodic

• NOISE- complex vibration has no repetitive pattern

• White noise- containing all frequencies in the audible spectrum at average equal amplitudes
• Narrow band noise- white noise with frequencies above and below a center frequency filtered out
or reduced
• Speech noise- white noise with frequencies above 3000 and below 300 Hz reduced by a filter
II. EXTERNAL EAR

• The external ear serves to funnel sound from the external

environment into the ear
• Sound localization

Interaural time difference Interaural amplitude difference

important for low-frequency sound localization important for higher frequencies

Head shadow effect- sound coming from one side is

attenuated by the head as the sound travels to the
contralateral ear
Interaural time difference Interaural amplitude difference
 RESONANT FREQUENCIES
CUMMINGS KJ LEE
RESONANT FREQUENCY RESONANT FREQUENCY
Concha 5300 Hz External auditory canal 3000 Hz
External auditory canal 3000 Hz Middle ear 800 - 5000 Hz
*mostly 1000 – 2000 Hz
Tympanic membrane 800 – 1600 Hz
Ossicular chain 500 – 2000 Hz

Resonance describes the phenomenon of increased amplitude that occurs when the frequency of a
periodically applied force is equal or close to a natural frequency of the system on which it acts.
III. MIDDLE EAR MECHANICS
• There are two pathways by which sound is transmitted by the middle ear
to the inner ear:

1) OSSICULAR COUPLING- pathway of sound transmission through the

actions of the tympanic membrane and the ossicular chain
2) ACOUSTIC COUPLING- pathway of sound transmission to the inner ear
in the absence of the ossicular system

• 60 dB
• Difference between ossicular coupling and acoustic coupling
• The maximal amount of hearing loss expected in patients with ossicular
discontinuity
 III. MIDDLE EAR MECHANICS
• Middle ear is composed of the:
a) Tympanic membrane (TM)
b) Ossicles—malleus, incus, and
stapes
c) Stapedius
d) Tensor tympani

• Ossicular chain has two

synovial joints that are mobile:
Incudomalleal and
incudostapedial joints
 III. MIDDLE EAR MECHANICS
• The TM has a conical shape to it, and its
medial surface is coupled to the
manubrium of the malleus.
• As sound stimulus enters the external
auditory canal, it causes the TM to vibrate.
• The malleus, which is coupled to the TM,
vibrates in response to the motion of the
TM.
• This causes the entire ossicular chain to
vibrate and results in sound transmission
to the inner ear via the stapes footplate.
• The ossicular chain vibrates along an axis
that projects through the head of the
malleus and the body of the incus in an
anteroposterior direction
• The stapes, the smallest bone in the body,
transmits the output of the middle ear into
the inner ear through the oval window.
III. MIDDLE EAR MECHANICS
The middle ear transforms acoustic energy from the medium of air to the
medium of liquid to allow for efficient sound transmission.

Because the inner ear is fluid filled, if a sound stimulus strikes the fluid
directly, most of the acoustic energy will be deflected, because the
impedance of fluid is much greater than the impedance of air.
III. MIDDLE EAR MECHANICS
IMPEDANCE MATCHING (Transformer action)

A. Area ratio between the TM and the stapes

footplate- most important factor

• If all the force applied to the TM were to be

transferred to the stapes footplate, the force per
unit area would be 20 times larger (26 dB) on the
69 mm2 3.4 mm2
footplate than on the TM
TM Surface
area:
20 X larger
III. MIDDLE EAR MECHANICS
IMPEDANCE MATCHING (Transformer action)
B. Lever ratio
• Because the manubrium is slightly longer
than the long process of the incus, a slight
force applied to the long arm of the lever
(manubrium) results in a greater force on
the short arm of the lever (incus long
process).

• In humans, the lever ratio is about 1.31 to 1

(2.3 dB).
 III. MIDDLE EAR MECHANICS
IMPEDANCE MATCHING (Transformer action)

area ratio lever ratio Theoretical

Actual gain
gain
26 dB 2 dB 20 dB
28 dB

Why only 20 dB?

• TM does not move as a rigid diaphragm
• At higher frequencies: multiple areas vibrate differently effective area of the TM involved with impedance
matching is smaller than its total area

• The 20 dB middle ear sound-pressure gain helps to facilitate sound transmission from the air-filled middle ear
into the fluid-filled inner ear
IV. INNER EAR PHYSIOLOGY

• Cochlea-shaped like a snail and has a spiral

configuration with two and a half turns
• The center portion of the spiral is called the
modiolus.
• The portion of the cochlea that is closest to
the oval window is referred to as the base,
whereas the portion of the cochlea that is
farthest away from the oval window is
referred to as the apex.
IV. INNER EAR PHYSIOLOGY
• The scala tympani and the scala media are
separated by the basilar membrane.
• The scala media and the scala vestibuli are
separated by the Reissner membrane.
• The scala tympani and the scala vestibuli join
together at the apex of the cochlea to form the
helicotrema.
• The scala media contains the organ of Corti, which
rests on the basilar membrane.
• the organ of Corti + basilar membrane= cochlear
partition
 IV. INNER EAR PHYSIOLOGY Stria vascularis-
responsible for the
maintenance of such a
large electrochemical
gradient; contains
multiple active ion
endocochlear channels and
potential maintains the
chemical composition
+60 to of the endolymph and
+100 mV its positive electrical
potential

Perilymph Endolymph
Location scala vestibuli and scala tympani scala media
(*cochlear duct, semi-circular ducts,
utricle and the saccule)
Potassium content Low High
Sodium Content High Low
IV. INNER EAR PHYSIOLOGY
IV. INNER EAR PHYSIOLOGY

• The vibration of the stapes footplate results in a compressional wave

in the inner ear fluid, which travels across the scala vestibuli, around
the helicotrema, and across the scala tympani toward the round
window; therefore an inward motion of the stapes causes an outward
motion of the round window.
• However, as this compressional wave travels across the scala vestibuli,
the pressure in the scala vestibuli is higher than the pressure in the
scala tympani.
• This sets up a pressure gradient, which causes the cochlear partition
to vibrate.
 IV. INNER EAR PHYSIOLOGY
Von Bekesy’s traveling wave theory:
 IV. INNER EAR PHYSIOLOGY
Von Bekesy’s traveling wave theory:

• As the cochlear partition is deflected by the compressional wave

created by the stapes footplate vibration, it sets up a traveling wave
on the basilar membrane, which travels from the base of the cochlea
to its apex
• The basilar membrane is tonotopically tuned to different frequencies
along its length
• The amplitude of the traveling wave peaks (resonates) at a specific
place along the basilar membrane, with the higher frequencies at the
base and the lower frequencies toward the apex.
IV. INNER EAR PHYSIOLOGY
stereocilia are deflected toward the direction of the tallest row
which causes the tip links to stretch

opening of stretch-sensitive cationic channels located on the

stereocilia causes a large influx of cationic current

hair cell depolarization causes calcium influx through channels

along the basolateral membrane of the hair cell

degranulation of neurotransmitter vesicles into the synaptic

terminal and propagates an action potential along the auditory
nerve
IV. INNER EAR PHYSIOLOGY
Resulting shearing force between the stereocilia of the hair cells and the tectorial
membrane causes the stereocilia to be deflected toward the direction of the tallest row
which causes the tip links to stretch

opening of stretch-sensitive cationic channels located on the stereocilia causes a

large influx of cationic current

hair cell depolarization causes calcium influx through channels along the basolateral
membrane of the hair cell

degranulation of neurotransmitter vesicles into the synaptic terminal and propagates

an action potential along the auditory nerve
IV. INNER EAR PHYSIOLOGY
stereocilia are deflected toward the direction of the tallest row
which causes the tip links to stretch

opening of stretch-sensitive cationic channels located on the

stereocilia causes a large influx of cationic current

hair cell depolarization causes calcium influx through channels

along the basolateral membrane of the hair cell

degranulation of neurotransmitter vesicles into the synaptic

terminal and propagates an action potential along the auditory
nerve
IV. INNER EAR PHYSIOLOGY Stereocilia are deflected away from
the tallest row

the tip links relax

decrease the probability of the ion

channel opening

hyperpolarization of the hair cell

IV. INNER EAR PHYSIOLOGY
OUTER HAIR CELL

- Change its length in response to

voltage changes
a. Contracts with depolarization
b. Elongates with hyperpolarization

- Prestin: voltage-dependent integral

membrane protein associated with
rapid changes in outer hair cell length

- Acts as a cochlear “amplifier” that

augments the signals transmitted into
the inner ear by the stapes vibration
Superior Semicircular Canal
Dehiscence Syndrome
(SCD)
Symptoms:
✓ Autophony
✓ Aural fullness
✓ Sound-induced vertigo (Tullio phenomenon)
✓ Pressure-induced vertigo
✓ Hearing loss

• The dehiscence acts as a third mobile window of the inner

ear that shunts acoustic energy away from the cochlea
and results in a decreased sensitivity to air-conducted
sound and the air-bone gap seen on audiologic testing
• This third window is also theorized to decrease cochlear input impedance at the oval window,
which increases the pressure gradient across the cochlear partition and results in hypersensitivity to
bone-conducted sound
V. AUDITORY NERVE
• Afferent auditory neurons
are bipolar in nature:
• Peripheral processes- to the
hair cells
• Central projections- to the
auditory brainstem

• Their cell bodies, also

known as spiral ganglion
cells (first order neuron),
are located in the Rosenthal
canal.
 V. AUDITORY NERVE
• As the sound pressure increases over a certain level, the afferent neurons begin to discharge at a rate higher
than that of the spontaneous rate.

Type I Type II
account for approximately 90% account for approximately 10%
myelinated unmyelinated
sends a single peripheral process to form a sends a peripheral process to form synapses
single synapse with a single inner hair cell with multiple outer hair cells

• The afferent auditory neurons are also tonotopically tuned as sound stimulus enters
the cochlea, its frequency components are analyzed by the basilar membrane as a series of filters.

• This frequency information is preserved through the hair cells and the auditory afferent neurons
and is transmitted to the central nervous system.
VI. AUDITORY BRAINSTEM AND
MIDBRAIN: COCHLEAR NUCLEUS
• Cochlear nucleus is the critical first relay station for all ascending
auditory information.
- located in the pontomedullary junction of the dorsolateral brainstem
• The ventral cochlear nucleus contains a number of different
cell types:
1. Spherical bushy cells [anteroventral cochlear nucleus
(rostral)]
2. Globular bushy and multipolar cells [centrally]
3. Octopus cells [posteriorly (caudal)]

• Both spherical and globular bushy cells (second order neuron)

receive large auditory terminals with multiple synaptic
specializations (end-bulbs of Held).
• Allows the bushy cells to have primary-like responses to Action
potentials from auditory nucleus preserving both temporal and
spectral information sent to high auditory brainstem nuclei,
the thalamus, and ultimately the auditory cortex.
• The end-bulbs of Held are vulnerable to sensory deprivation, and
congenital deafness is associated with unambiguous changes in
these large synaptic terminals.
VI. AUDITORY BRAINSTEM AND
MIDBRAIN: SUPERIOR OLIVARY
COMPLEX
• serves as a relay station for auditory
information from both ears

• located medial to the cochlear nucleus in

the caudal portion of the pons

• The superior olivary complex (SOC) is located

medial to the cochlear nucleus in the
caudal portion of the pons.

• It contains three main nuclei:

1. the medial superior olive (MSO)
2. the lateral superior olive (LSO)
3. the nucleus of the trapezoid body
VI. AUDITORY BRAINSTEM AND
MIDBRAIN: SUPERIOR OLIVARY
COMPLEX
1. Plays an important role in sound localization by analyzing
interaural time differences (MSO) and interaural amplitude
differences(LSO)

2. Helps to enhance auditory perception by two additional

mechanisms:
a) Binaural squelch - ability to increase the signal-to-noise
ratio of the incoming sound stimulus through information
processing
b) Summation - a sound signal received by both ears is
greater in amplitude (by 3 dB) than the same signal
received by a single ear.
✓ This increase in perceptual loudness is thought to
improve speech intelligibility in noisy environments

3. Plays an important role in the efferent pathways of the auditory

system
VI. AUDITORY BRAINSTEM AND
MIDBRAIN: LATERAL LEMNISCUS
• formed by the three fiber tracts from the
cochlear nucleus:
1. Dorsal stria- the stria of Monaco
2. Intermediate stria- the stria of Held
3. Ventral stria- trapezoid body
VI. AUDITORY BRAINSTEM AND
MIDBRAIN: INFERIOR
COLLICULUS
• Located in the midbrain just caudal to the superior
colliculus.

• Integrates information from both auditory and nonauditory

sources
➢ receives auditory inputs from the lateral lemniscus, the
cochlear nucleus, and the SOC
➢ it receives projections from the somatosensory, visual, and
vestibular systems

• Processes the information it receives and sends fibers to

the medial geniculate body of the thalamus
VII. THALAMUS AND AUDITORY
CORTEX : MEDIAL GENICULATE
BODY
• The thalamic auditory relay

• Play an important role in sound localization and processing

of complex vocal communications

• Three divisions:
a) Ventral division- projects to the primary auditory cortex
b) Dorsal division projects to the auditory association
cortex
c) Medial
VII. THALAMUS AND AUDITORY
CORTEX : AUDITORY CORTEX
Auditory Association
Primary Auditory Cortex
Cortex
located on the superior
located lateral to the primary
surface of the temporal lobe
auditory cortex
(Heschl gyrus)

Area A1; corresponds to Area A2; corresponds to

Brodmann area 41 Brodmann areas 22 and 42

tonotopically tuned:
• High frequencies-more part of a language reception
medially area known as the Wernicke
• Low frequencies- more area
laterally

involved with integrating and

processing complex auditory
signals, which includes
language comprehension
 VII. THALAMUS AND AUDITORY
CORTEX : AUDITORY CORTEX
• The primary auditory cortex is located on the Heschl gyrus
and is tonotopically organized.
➢ This region processes complex auditory signals to enable
language comprehension.

• The main auditory portion of the cerebral cortex resides in the

temporal lobe, close to the sylvian fissure.

• Auditory information from the subcortical structures also

project to other parts of the brain, such as the amygdala,
which is a part of the limbic system.
➢ This can help to explain why sounds such as music can
evoke strong emotional responses.
WERNICKE’S VERSUS BROCA’S APHASIA
VIII. EFFERENT AUDITORY SYSTEM: MIDDLE
EAR MUSCLE REFLEX PATHWAYS

STAPEDIUS TENSOR TYMPANI

Origin interior of pyramidal eminence of cartilaginous portion of the eustachian tube
tympanic cavity
Insertion posterior neck of the stapes capitulum neck of the manubrium of the malleus
Innervation Stapedial nerve (Facial nerve) Mandibular branch of the Trigeminal nerve
Action contraction stiffens the stapes Muscular contractions pull the malleus in an inward
superstructure and increases middle direction and stiffen the TM and ossicles, thus increas-
ear impedance ing the acoustic impedence
VIII. EFFERENT AUDITORY SYSTEM: STAPEDIUS
REFLEX PATHWAYS Intense, low-frequency sound, or broadband
noise activate contraction of the ipsilateral
stapedius muscle

the action potential is propagated along the

auditory nerve and activates unidentified
interneurons located in the ventral cochlear
nucleus

Interneurons project from the cochlear nuclei to

and synapse on the stapedius motoneurons
synapse (black and gold terminals).

Efferent motor projections that originate in

stapedius motoneurons terminate on the
stapedius muscle.
VIII. EFFERENT AUDITORY SYSTEM: MIDDLE EAR
MUSCLE REFLEX PATHWAYS
• Functions of the middle ear muscle reflex pathway
1. modulation of middle ear impedance and attenuation of acoustic energy that reaches
the cochlea
➢ This reflex arc can reduce sound transmission through the middle ear at high levels, and may serve to
control the dynamic range of the auditory system and to protect the cochlea at high sound levels.

2. high-pass filtration of low-frequency sound (background noise) to prevent masking of

speech frequencies
➢ Low-frequency sounds, particularly when they are high in level, normally tend to mask mid- and high-
frequency sounds due to their upward excitation patterns on the BM.
➢ One role of the middle-ear muscles is to reduce the level of low-frequency inputs so they do not mask
the higher frequency sounds on the BM

3. prevents overstimulation from self-generated vocalization or swallowing

➢the reduction of the audibility of self-generated sounds during speech, mastication, yawning, and
sneezing
VIII. EFFERENT AUDITORY SYSTEM:
OLIVOCOCHLEAR REFLEX PATHWAYS

MEDIAL OLIVOCOCHLEAR (MOC) FIBERS LATERAL OLIVOCOCHLEAR (LOC) FIBERS

innervate the auditory nerves under the inner hair

innervate the outer hair cells
cells

large and myelinated thin and unmyelinated

more sensitive to low-frequency sound information more responsive to higher frequency information
VIII. EFFERENT AUDITORY SYSTEM: OLIVOCOCHLEAR
REFLEX PATHWAYS sound activates the afferent auditory
fibers, which innervate the interneurons in
the ipsilateral posteroventral cochlear
nucleus

the interneurons of the cochlear nucleus

innervate the contralateral MOC neurons

the contralateral MOC neurons (ipsi

neurons) send fibers to the ipsilateral
cochlea
 VIII. EFFERENT AUDITORY SYSTEM:
OLIVOCOCHLEAR REFLEX PATHWAYS
• The functions of the OC efferent pathways, especially the MOC pathway:
1. protect the ears from acoustic trauma
➢ Main function: decrease the cochlear responses by decreasing the gain of the cochlear amplifier
(Main function)
➢ How: Cause hyperpolarization of the outer hair cells through an acetylcholine-mediated pathway
➢ Evidence: elevated sound level required for auditory nerve activation (level shift), as well as the
blunting of the tuning curve at the characteristic frequency

2. to discriminate transient sounds from background noise

➢ the MOC pathway decreases the auditory responses to the background noise more
neurotransmitters are preserved for use in response to transient sounds (unmasking)
 SUMMARY
External Ear: Middle ear: Inner ear: Ascending auditory
Acoustic Mechanical Electrochemical pathway:
signal Signal signal Action potential

E
C
O
L
I
M
A

• Descending pathways to the ear (auditory efferents) modulate the response of the middle ear
(acoustic reflex) and inner ear (medial olivocochlear reflex) to certain types of sounds
➢ prevent acoustic overstimulation and also enhance speech discrimination in background noise.
THANK YOU AND GOOD
NIGHT
END OF PRESENTATION.