AJNR Am J Neuroradiol 26:1317–1323, June/July 2005

Foramen Tympanicum, or Foramen of Huschke:

Pathologic Cases and Anatomic CT Study
Alexis Lacout, Kathlyn Marsot-Dupuch, Wendy R. K. Smoker, and Pierre Lasjaunias

BACKGROUND AND PURPOSE: A persistent foramen tympanicum, or foramen of Huschke,

is an anatomic variation of the tympanic portion of the temporal bone due to a defect in normal
ossification in the first 5 years of life. The foramen is located at the anteroinferior aspect of the
external auditory canal (EAC), posteromedial to the temporomandibular joint (TMJ). We
sought to define its prevalence, location, and size on high-resolution spiral CT (HRCT).
METHODS: We prospectively examined 102 consecutive HRCT studies of the temporal bone
(204 ears). HRCT was performed by using 120 kV, 400 mAs, an ultra– high-resolution filter,
0.6-mm section thickness, 0.3-mm section increment, 728 ⴛ 728 matrix, and 160-mm field of
view. We noted the size and location of the foramen tympanicum relative to the tympanic
membrane and calculated its prevalence. Patients with focally decreased tympanic bone thick-
ness of <1 mm at the anteroinferior EAC (between the 3- and 6-o’clock positions) were
considered separately.
RESULTS: We found a foramen tympanicum was found in six (4.6%) of 130 ears. Mean axial
diameter was 4.2 mm, and mean sagittal diameter was 3.6 mm. Focally reduced bone thickness
in the same location was found in 45 (35%) ears, with a female preponderance (P ⴝ .003).
CONCLUSION: HRCT is sensitive for detection of the foramen tympanicum because of its
thin sections, high spatial resolution, and multiplanar capabilities. Awareness of this anatomic
entity may be useful in evaluating patients with transient otorrhea in whom no otologic cause
(e.g., ear infection, TMJ disease) is identified.

The foramen tympanicum, also known as the foramen dispose the person to the spread of infection or tumor
of Huschke, is an anatomic variation in the tympanic from the EAC to the infratemporal fossa, and vice
portion of the temporal (tympanic) bone. When versa (1, 6, 9). The purpose of this study is to define
present, it is located at the anteroinferior aspect of the prevalence, precise location, and size of the fora-
the external auditory canal (EAC), posteromedial to men tympanicum by using high-resolution spiral CT
the temporomandibular joint (TMJ) (1, 2) (Fig 1). (HRCT).
Focal reduction of tympanic bone thickness may also
be observed in the same location (3) (Fig 2).
A foramen tympanicum may predispose individuals Methods
to TMJ pathology (4), or it may be associated with We prospectively evaluated 102 consecutive HRCT stud-
ies of the temporal bone (204 ears). Each study (MX 8000
salivary discharge into the EAC during mastication
quad; Philips Medical Systems, Eindhoven, the Netherlands)
(5, 6). During TMJ arthroscopy, inadvertent passage was performed by using the following parameters: 120 kV,
of the arthroscope into the EAC and resultant oto- 400 mAs, ultra– high-resolution filter, 0.6-mm section thick-
logic complications has also been reported (7, 8). ness, 0.3-mm section increment, 728 ⫻ 728 matrix, and
Persistence of the foramen tympanicum may also pre- 160-mm field of view. Therefore, the in-plane resolution was
equivalent to 0.21 mm. We considered the bony foramen was
present when its dimension was greater than twice the pixel
size (0.42 mm). Axial and multiplanar reformatted images in
Received May 25, 2004; accepted after revision December 11.
sagittal and coronal planes were studied. Axial images were
From the Department of Neuroradiology, Bicêtre Hospital, Paris
acquired in the orbitomeatal plane.
XI University, France (A.L., K.M.-D., P.L.), and the Department
of Radiology, University of Iowa Hospitals and Clinics, Iowa City
Patients with a history of ear surgery or temporal bone
(W.R.K.S.). trauma or fracture and those younger than 5 years were
Presented at the 42nd Annual Meeting of the American Society excluded. We also excluded technically suboptimal HRCT
of Neuroradiology, Seattle, WA, June 5–11, 2004. scans. A senior neuroradiologist (K.M.-D.) and one in train-
Address correspondence to Kathlyn Marsot-Dupuch, Depart- ing radiologist (A.L.) independently analyzed the HRCT
ment of Neuroradiology, Bicêtre Hospital, Paris XI University, 78 studies. We considered only anteroinferior bony dehiscences
rue du Général Leclerc, 94270 Le Kremlin Bicêtre, France. because they corresponded to the anatomic site of the fora-
men tympanicum where the developmental ossification
© American Society of Neuroradiology prominences fuse (e.g., between the 3- and 6-o’clock posi-

1317
1318 LACOUT AJNR: 26, June/July 2005

FIG 1. HRCT sections of the temporal bone through the inferior portion of the EAC. Images show the anteroinferior location of the
foramen tympanicum, posterior to the TMJ (arrowhead).
A, Axial.
B, Sagittal.

FIG 2. Axial HRCT sections of the temporal bone in two patients through the same level at the inferior portion of the EAC.
A, Normal tympanic bone.
B, Focal anteroinferior reduction in tympanic bone thickness 2 mm lateral to the tympanic membrane (arrowhead).

tions). We identified the foramina on axial images and Results

confirmed their existence on coronal and sagittal reformat-
ted images. For every patient, we noted the presence of a Thirty-seven of the 102 HRCT studies were excluded
foramen, its size, and its location in relation to the tympanic from further evaluation: 31 because of previous tempo-
membrane. We measured the size of the foramen in the axial ral bone surgery, five because of previous temporal-
plane, as well as on the reconstructed coronal and sagittal
planes. We measured its distance to the anterior insertion of
bone trauma, and one because the scans were techni-
the tympanic membrane to determine its precise location. cally suboptimal. Studies in the remaining 65 patients
We calculated the prevalence of the persistent foramen (130 temporal bones) formed the basis of our investiga-
tympanicum. Patients in whom the tympanic bone was less than tion. The patients included were 32 male patients (mean
1 mm thick were considered separately. An additional open- age, 42 years; range, 11–73) and 33 female patients
mouth HRCT of the temporal bone was performed in one (mean 49 years; range, 7–92 years) with an overall mean
patient in whom a foramen tympanicum was detected. This was
done to demonstrate dynamic soft-tissue herniation through
age of 45 years (range, 7–92 years). Indications for
the foramen that might explain the patient’s TMJ pain. We HRCT were hearing loss (36 patients), chronic otitis (17
informed the patient of the clinical relevance and prospective patients), infections (four patients), tumors (five pa-
nature of our study. tients), and miscellaneous (three patients).
AJNR: 26, June/July 2005 FORAMEN TYMPANICUM 1319

We identified six (4.6%) of 130 ears with a persis-

tent foramen tympanicum. This was found in four
(6%; three female, one male) of 65 patients (1 mol/L)
and was unilateral in two patients (two female; 0
mol/L) and bilateral in two (one female, one male; 1
mol/L). The shape of the foramina was considered
oval because their dimensions in two planes were
slightly different. Their mean size was 4.2 mm in the
axial plane (range, 2.8 – 4.8 mm) and 3.6 mm in the
sagittal plane (range, 2.2–5.3 mm). The tympanic
membrane was always identified on these images,
near the persistent tympanic foramen with a mean
distance of 1.0 mm (range, 0 –2.2 mm). One tympanic
foramen was continuous with the tympanic sulcus.
HRCT scans in the one patient with a persistent
foramen tympanicum who underwent the additional
study showed was no herniation of soft tissue through
the foramen.
Forty-five (35%) of 130 tympanic bones had de-
creased thickness (⬍1.0 mm) at the anteroinferior
portion. The 45 affected tympanic bones were FIG 3. Axial HRCT sialograms (soft tissue window) of the left
found in 27 (42%) of our 65 patients. Eighteen parotid gland through the inferior portion of the EAC show (ar-
patients (28%; 12 female, six male) of the 65 had row) submucosal nodular enhancement in the foramen tympani-
bilateral involvement (6 mol/L), whereas nine cum, suggesting ectopic salivary-gland tissue.
(14%; four female, five male) had unilateral in-
volvement (5 mol/L). enhancing, periarticular soft-tissue mass herniating
through a foramen tympanicum into the EAC (Fig
4C). No treatment was performed because of the
Discussion patient’s age.
We previously observed two patients with pathol- The tympanic bone, which contributes to forma-
ogies related to a persistent foramen tympanicum tion of the EAC and tympanic cavity, develops from
who provided the impetus for our present investi- a membranous ossification process (10, 11). Devel-
gation. The first was a 52-year-old woman who opment of the tympanic bone explains the differ-
complained of clear discharge from her left EAC. ence in orientation between infants and adults. The
Symptoms occurred only when she was eating; this tympanic membrane is formed in utero by the con-
suggested a salivary fistula. She had no history of nection of the first entoblastic and epiblastic
trauma or tympanic bone surgery. High-resolution pouches. At 9 weeks’ gestational age, four ossifica-
CT sialography of the left parotid gland was per- tion centers develop around the tympanic mem-
formed after catheterization of Stenson duct and brane, fusing to form a U-shaped bone (7). This
the injection of 2 mL of iodinated contrast agent. bone fuses with the squamous portion of the tem-
HRCT scans of the temporal bone were obatined poral bone during the 35th week of gestational age.
and reviewed in both bone and soft tissue windows. Therefore, at birth, the entire tympanic bone is
Submucosal and nodular enhancement in a large incompletely developed and forms a U shape. Two
osseous defect of the tympanic bone was observed, prominences, one anterior and one posterior to the
suggesting ectopic salivary gland tissue (Fig 3). U-shaped bone, arise and grow toward each other.
However, we detected no extravasation of contrast These two points of ossification fuse at the age of 1
agent into the EAC during HRCT sialography. An year, the first step of EAC development. The fora-
open-mouth HRCT scan showed no change in the men tympanicum persists medial to the point of
soft tissue swelling. The patient underwent success- fusion. In most children, the foramen tympanicum
ful surgical closure of the fistula. gradually becomes smaller and completely closes
The second patient was a 90-year-old woman who before the age of 5 years, but it occasionally persists
presented with right external otitis. She complained (1, 10) (Fig 5). Therefore, tympanic bone dehis-
of a long history of chronic TMJ pain. Clinical exam- cence present at the precise point of fusion of the
ination revealed dome-shaped swelling on the right two prominences should be considered an anatomic
anteroinferior EAC wall. HRCT of the temporal variant only after the age of 5 years (12).
bone demonstrated an anterior bony dehiscence of Many factors influence the ossification process of
the right EAC, a soft-tissue mass extending from the the tympanic bone after birth. Mechanical environ-
TMJ into the EAC, and air pockets in the TMJ region ment of the mandible against the tympanic bone is
(Fig 4A). Open-mouth HRCT showed anterior re- one factor to consider. The maxillofacial and tym-
traction of the mass into the TMJ region (Fig 4B). panic bones grow after birth, primarily in response to
T1-weighted MR images (TE/TR, 500/15) obtained pressure created by the actions of mastication, deglu-
with and without gadolinium enhancement showed an tition, and respiration (12, 13). Therefore, we can
1320 LACOUT AJNR: 26, June/July 2005

FIG 4. Axial HRCT sections (bone window) of the temporal bone

through the inferior portion of the EAC.
A, Closed-mouth view shows herniation of soft tissue herniation
into the EAC 2 mm lateral to the tympanic membrane (arrowhead).
B, Open-mouth view show subcutaneous air pockets spreading
along the TMJ (arrow). Slight retraction of the soft tissue material
is noted when the mouth is open.
C, Contrast-enhanced T1-weighted MR image (TE/TR, 500 /15)
through the inferior portion of the EAC shows enhancement of the
herniating soft tissue (arrowhead).

FIG 5. Schema illustrates normal post-

natal development of the tympanic bone
(used with permission from Anson BJ,
Donaldson JA. Surgical Anatomy of the
Temporal Bone. 3rd ed. Philadelphia:
W. B. Saunders; 1981:122).

hypothesize that the tympanic foramen is an osseous sustained by the tympanic bone on the development
developmental defect. The influence of the pressures of the TMJ is probably great. We also hypothesized
AJNR: 26, June/July 2005 FORAMEN TYMPANICUM 1321

Foramen tympanicum reported in the literature

Side and
Patient Age (y)/Sex History Physical Finding Imaging Finding Diagnosis
3
Heffez et al. 1989
67/F R, pain Swelling/OMR CT: bony defect, MRI: herniation TMJ herniation
53/F R, pain Swelling/OMR Polystomograms: tympanic plate TMJ herniation
defect
Weissman et al, 19914
15/F L Swelling/OMR NA TMJ herniation
Sharma et al, 19845
58/F R, otorrhea Anterior punctum, flow while NA Salivary fistula
sucking on a sweet
Chilla, 20026
62/F L, otorrhea Anterior polyp NA Salivary fistula
Dingle, 19927
75/M R, pain Swelling/OMR NA EAC fistula
Tahir and Rubinstein 200017
64/M R, HL Clear fluid on anterior wall CT: bony defect Arthritis
Hawke et al, 198718
68/F R/L, HL Swelling/OMR CT: anterior bony defect, soft tissue Meniscus herniation
herniation/OM anterior retraction
Cecire and Austin, 199119
60/M L, otorrhea Polyp CT: anterior defect, soft tissue Polyp
herniation
Hawke et al, 198820
58/F R, otorrhea Swelling/OMR CT: R/L dehiscence of anterior wall EAC fistula
Our study
52/F L, otorrhea Normal Sialo-CT: subcutaneous nodular Salivary fistula
enhancement
90/F R, pain Swelling CT: soft tissue herniation TMJ herniation
Our series
58/F L NA CT: foramen tympanicum NA
38/F R/L NA CT: foramen tympanicum NA
92/F R NA CT: foramen tympanicum NA
39/M R/L NA CT: foramen tympanicum NA

Note.—NA ⫽ not applicable, OMR ⫽ retraction upon opening of mouth, HL ⫽ hearing loss.

that dehiscence of the tympanic bone is linked to tions studied: rates were 6.7% in the skulls from
abnormal development of the first branchial arch. China and 9.1% in skulls from Toronto (1). However,
However, anomalies of the first branchial arch end at this study may have had a high rate of false-positives
the inferior part of the EAC at a different place of a because of the manipulation of fragile bones. The
persistent foramen tympanicum (14). Furthermore, investigators found that the foramen is very near the
the tympanic ring could have a role in ossification of tympanic membrane, in agreement with our findings,
the tympanic bone, as congenital cholesteatoma has and they also reported the same mean dimension of 3
been linked to abnormal development of the tym- mm (range, 1– 6 mm).
panic ring, which cannot stop the migration of the To our knowledge, the sex distribution of the fora-
EAC ectodermal tissue into the middle ear (15). men tympanicum has not been studied. Among our
Therefore, an anomaly of the tympanic ring during four patients with a foramen tympanicum, three were
embryogenesis could lead to an abnormal ossification female, but this sample was not a large enough for us
of the tympanic bone and to a persistent foramen to suggest a female preponderance for the foramen
tympanicum. We also suggest that persistence of the tympanicum. However, most patients with foramen
foramen tympanicum may be linked to genetic factors tympanicum reported in the literature were female
promoting a focal anomaly of ossification (13). (Table). We also observed a female preponderance
The foramen tympanicum is a variant of ossifica- among our patients with focal reduction of tympanic-
tion that transmits no neural or vascular structures. It bone thickness (P ⫽ .003). Therefore, the female
is an osseous defect closed by a membranous struc- distribution of abnormal ossification might have been
ture. The term foramen is defined by a structure due to differences in growth and development of the
traversing it (16). Therefore, the foramen tympanicum mandible between male and female individuals.
is not a true foramen; is may be more appropriately Pathology associated with a foramen tympanicum
termed a bony or osseous defect or dehiscence. is occasionally reported (Table). A foramen tympani-
Wang et al (1) found a rate of persistent foramen cum may permit spontaneous herniation of soft tissue
tympanicum of 7.2% in an osteologic study (377 from the TMJ into the EAC, which can cause TMJ
skulls), with some differences between the popula- pain and dysfunction (2, 3, 17–19). These herniations
1322 LACOUT AJNR: 26, June/July 2005

are characteristic and fairly easy to identify because the EAC and the infratemporal fossa via a small
they usually retract out of the EAC with anterior millimetric canal located at the anteroinferior part
translation of the TMJ that occurs during opening of of the tympanic bone.
the mouth (3, 4, 17–19). Therefore, soft-tissue pro-
trusion into the EAC is usually visible only when the
patient’s mouth is closed, and it may completely dis- Conclusion
appear when the mouth is opened. The origin of this The foramen tympanicum is well-demonstrated on
herniation is unclear (3, 4, 19), but it has been re- HRCT and not uncommon, occurring in 4.5% of the
ported as a complication of external otitis (9) and ears in our cohort. This osseous defect may be due to
TMJ arthritis (17). Herniation of the posterior and abnormal mechanical forces during postnatal facial
deep insertions of the TMJ meniscus through the development and/or ossification abnormalities due to
foramen tympanicum into the EAC has also been genetic factors. Variations in the tympanic bone may
reported (18). be associated with certain pathologic conditions and
A foramen tympanicum may also facilitate ear in- should be systematically excluded on all HRCT ex-
jury during TMJ arthroscopy performed with an en- aminations regardless of the patients’ clinical symp-
doscope of less than 3 mm in diameter, which may toms. Because no neurovascular structures traverse
penetrate into the EAC by traversing the persistent the foramen tympanicum, it is not a true foramen, but
foramen (7, 8). Reported otologic complications are rather, a defect of tympanic bone ossification. There-
tympanic membrane rupture, dislocation of the incus, fore, according to modern concepts of anatomy, the
injury to the tympanic segment of the facial nerve, foramen tympanicum, or the foramen of Huschke,
labyrinthine disruption, and ear infection (7). Other seems to be a misnomer and should be called tym-
associated pathologies are related to otorrhea with- panic bone dehiscence.
out any evident otologic causes. Both salivary-gland
fistulas (4, 17) and synovial TMJ fistulas are reported
(20). However, biochemical analysis of EAC dis- Acknowledgments
charges is often difficult because of small samples. We thank Thor Bessier, Stanford University, and Dupuch
Otorrhea usually begins with TMJ movement during Sonia, Philips, San Jose, CA, for their help and suggestions on
mastication and is not specific to either salivary or this article. We also thank the Dr Chng Soke Miang for her
TMJ fistulas, as mastication causes salivary gland se- help.
cretions and TMJ movements facilitate synovial dis-
charge into the EAC. The parotid gland can extend to References
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