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KJ Lee Essential Medicine Series

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KJ Lee Essential Medicine Series

K. J. Lee, MD, FACS - Series Editor-in-Chief

Yale University School of Medicine
Quinnipiac University Netter School of Medicine
Hamden, Connecticut, USA
Hofstra University Zucker School of Medicine
Hempstead, New York, USA

Essential Head and Neck Oncology and Surgery

Maie A. St. John, MD, PhD, FACS (Editor)
Benjamin L. Judson, MD, MBA (Editor)
Josephine H. Nguyen, MD (Assistant Editor)
2023. ISBN: 979-8-88697-438-6 (Hardcover)
2023. ISBN: 979-8-88697-746-2 (e-book)

Essential Sleep Medicine and Surgery

Maria V. Suurna, MD, FACS (Editor)
Stacey L. Ishman, MD (Editor)
Josephine H. Nguyen, MD (Assistant Editor)
2022. ISBN: 978-1-68507-220-9 (Hardcover)
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Maie A. St. John
and Benjamin L. Judson
Editors

Josephine H. Nguyen
Assistant Editor

Essential Head and Neck Oncology

and Surgery
Copyright © 2023 by Nova Science Publishers, Inc.
DOI: https://doi.org/10.52305/WVLB7531

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Library of Congress Cataloging-in-Publication Data

Names: St. John, Maie A., M.D., Ph.D., FACS, editor. | Judson, Benjamin L., editor.
Title: Essential head and neck oncology and surgery / Maie A. St. John, MD, PhD, FACS (editor),
Department of Head and Neck Surgery, David Geffen School of Medicine, University of California,
Los Angeles, Los Angeles, CA, USA, Benjamin L. Judson, MD, MBA (editor), Division of Otolaryngology,
Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
Identifiers: LCCN 2023012174 (print) | LCCN 2023012175 (ebook) | ISBN
9798886974386 (hardcover) | ISBN 9798886977462 (adobe pdf)
Subjects: LCSH: Head--Cancer--Treatment. | Neck--Cancer--Treatment. |
Head--Cancer--Surgery. | Neck--Cancer--Surgery.
Classification: LCC RC280.H4 E86 2023 (print) | LCC RC280.H4 (ebook) |
DDC 616.99/491--dc23/eng/20230414
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LC ebook record available at https://lccn.loc.gov/2023012175

Published by Nova Science Publishers, Inc. † New York

 This book is affectionately dedicated to my patients whose courage
is my guiding light.

To my parents whose interest in this, as in all my ventures was never

less than my own.

To my dear husband Rick, whom I met in college, and who has made
every single moment of my life better ever since.

The final word of gratitude is to my incredible three sons for teaching me

that indeed only from the heart can you touch the sky.

Maie A. St. John

This book is dedicated to my wife Kara, and our sons Sam and Nate.

I would like to thank my mentors, teachers, colleagues, and friends whose support
and company have made travel along this career path possible and a joy.

Finally, I hope readers gain something from this book that helps them care
skillfully and compassionately for their patients.

Benjamin L. Judson
Contents

Foreword and Acknowledgments ......................................................................................... xi

Preface .................................................................................................................... xiii
Additional Acknowledgments .............................................................................................. xv
Chapter 1 Oral Cavity, Pharynx, and Larynx Anatomy, Physiology,
and Other Basics .......................................................................................... 1
Sagar Kansara, MD, Dennis Kraus, MD and Patrick Ha, MD
Chapter 2 Temporal Bone and Skull Anatomy, Physiology,
and Other Basics ........................................................................................ 11
Sujana S. Chandrasekhar, MD
and Hosakere K. Chandrasekhar, MD
Chapter 3 Neck Spaces and Fascial Planes ................................................................ 31
Omar A. Karadaghy, MSCI, MD, Mia Jusufbegovic, MD,
Jeffrey M. Blumberg, MD, FACS
and Yelizaveta Shnayder, MD, FACS
Chapter 4 Thyroid and Parathyroid Glands ............................................................. 51
Tyler R. Halle, MD, Lindsay C. Boven, MD,
Amr H. Abdelhamid Ahmed, Amy Y. Chen, MD
and Gregory W. Randolph, MD
Chapter 5 Salivary Gland Diseases ............................................................................ 99
Rosh K. V. Sethi, MD, MPH, Wojciech K. Mydlarz, MD,
David Eisele, MD and Daniel G. Deschler, MD
Chapter 6 Cysts and Neoplasms of the Mandible and Maxilla .............................. 123
Tara Aghaloo, MD, PhD, Ali Salehpour, MD, Brett A. Miles, MD
and David Hirsch, MD
Chapter 7 Carotid Body Tumors, Paragangliomas and Vascular
Anomalies ................................................................................................. 177
Paul Zolkind, MD, Tammara Lynn Watts, MD
and Davud Sirjani, MD
Chapter 8 Leukoplakia, Erythroplakia, and Premalignant Lesions ..................... 189
Hunter Archibald, MD, Ashok Jethwa, MD
and Frank Ondrey, MD, PhD
viii Contents

Chapter 9 TNM Staging in Head and Neck Cancers .............................................. 207

Michael H. Berger, MD, Jose P. Zevallos, MD
and William B. Armstrong, MD
Chapter 10 Overview of Guidelines and Evidence Based Care in Head
and Neck Cancer ...................................................................................... 229
Saral Mehra, MD, MBA, Oded Cohen, MD
and Babak Givi, MD
Chapter 11 Non-Melanoma Skin Cancers ................................................................. 241
Arielle Thal, MD, Thomas J. Ow, MD, MS, FACS
and Cecelia E. Schmalbach, MD, MSc, FACS
Chapter 12 Malignant Melanoma of the Head and Neck ......................................... 257
Peter Yao Kelly Malloy, MD and Luc G. T. Morris, MD
Chapter 13 Tumors of the Oral Cavity and Oropharynx ........................................ 275
Danielle M. Bottalico, MD, Amy C. Hessel, MD
and Richard Smith, MD
Chapter 14 HPV+ Oropharyngeal Cancers: Today and Tomorrow ....................... 313
Donovan Eu, MD, FAMS, Ameya A. Asarkar, MD, FACS
and Jonathan Irish, MD, FRCS
Chapter 15 Tumors of the Larynx, Hypopharynx, and Cervical Esophagus ......... 331
Ameya A. Jategaonkar, MD, Timothy Blood, MD,
Dinesh K. Chhetri, MD and David M. Cognetti, MD
Chapter 16 Skull Base and Sinonasal Tumors .......................................................... 347
Janet Chao, MD Thad Vickery, MD Michelle Chen, MD, MHS,
R. Peter Manes, MD and Daniel M. Beswick, MD
Chapter 17 Minimally Invasive Surgical Techniques for the
Management of Head and Neck Cancers ............................................... 367
Umamaheswar Duvvuri, MD, PhD
and Benjamin L. Judson, MD, MBA
Chapter 18 Neck Dissection and Management of the Neck...................................... 383
Samuel Auger, MD, Gina Jefferson, MD, MPH, FACS
and Nishant Agrawal, MD
Chapter 19 Head and Neck Reconstructive Surgery ................................................ 397
Kristen A. Echanique, MD, Joseph B. Meleca, MD,
Heather Edwards, MD, Michael Fritz, MD, FACS
and Rhorie P. R. Kerr, MD
Chapter 20 Chemotherapy, Targeted Therapy and Clinical Trials ........................ 425
Kartik Sehgal, MD, Deborah J. Wong, MD, PhD
and Robert Haddad, MD
 Contents ix

Chapter 21 Immunosurveillance and Immunotherapeutic Approaches

in Head and Neck Cancer........................................................................ 437
Vikash Kansal, PhD, Robert L. Ferris, MD, PhD
and Nicole C. Schmitt, MD
Chapter 22 Targeted Radiation for Head and Neck Cancer:
Specificity and De-Escalation.................................................................. 453
James H. Laird, MD Jie Deng, MD, PhD, Sumi Sinha, MD,
Robert K. Chin, MD, PhD, Sue S. Yom, MD, PhD
and Henry S. Park, MD, MPH
Chapter 23 Surviving and Thriving: Survivorship in the 21st Century .................. 469
Jymirah R. S. Morris, David A. Rapkin, PhD,
Marci L. Nilsen, PhD and Jonas T. Johnson, MD
Chapter 24 It Takes a Village: State of the Art Multidisciplinary Care ................. 507
Kenric Tam, MD, Catherine T. Haring, MD,
Carol R. Bradford, MD and Maie A. St. John, MD, PhD
Answers to Multiple Choice Questions.............................................................................. 5
About the Editors ................................................................................................................ 525
List of Contributors ............................................................................................................ 527
Index ................................................................................................................... 537
Foreword and Acknowledgments

As the knowledge of medicine has grown exponentially, it is necessary to have books each
encompassing one subspecialty. I had the vision of creating a book for each subspecialty
building from the formula and on the success of Essential Otolaryngology-Head and Neck
Surgery, the inceptive book, which is in its 12th Edition, 49th year, and has been translated into
several languages. It was cited as one of the most read texts in the field worldwide. Working
with President Nadya S. Gotsiridze-Columbus, CEO of Nova Science Publishers, Inc., we
developed K. J. Lee Essential Medicine Series, to host the subspecialty books. After a national
search, we were fortunate to have Dr. Ben Judson and Dr. Maie St. John to be Editors of this
book and Dr. Josephine Nguyen to be Assistant Editor to compile the ever important Practice
Guidelines. We commend the scholarly contents of the chapter contributing authors. It is with
great pleasure and honor for me to say they all worked very hard and have done a superb job.
I thank them all and kudos to them.
Like the inceptive book, I have no doubt this book will find its way to libraries, to the
reference sections of emergency rooms, urgent care centers, as well as the dorm rooms,
apartments, and homes of medical students, residents, fellows, young attendings, physician
assistants, nurse practitioners and others.
This book is not only a great text and reference for medical professionals, but it can also
be of value for people outside the medical field to understand key concepts in order to better
communicate with providers.

K. J. Lee, MD, FACS, Editor-in-Chief

KJ Lee Essential Medicine Series
Preface

This textbook presents a succinct yet comprehensive overview of the current essential topics in
the multidisciplinary care of head and neck cancer patients. With each chapter written by
experts in the many fields that comprise head and neck oncology and surgery, this compendium
provides a unique, multidisciplinary perspective on the diagnosis and management of these
patients. Information is presented in outline format to optimize the learning experience with
multiple-choice questions to consolidate learning and practice guidelines to strengthen one’s
grasp of the topics while presenting the opportunity for efficient reference. Finally, this
textbook’s outline format, clear and concise language, and rich set of practice guidelines make
it a trusted resource for nonmedical professionals hoping to learn more about head and neck
cancer patients and their treatments.
Additional Acknowledgments

We wish to thank Penny Amescua and Christy Collins, whose tireless efforts, and unparalleled
attention to detail, brought this book to fruition.
We also would like to thank the chapter authors who have contributed their invaluable
expertise and precious time which has made this book a reality.
Finally, we wish to thank our inimitable mentor, Dr. K.J. Lee, who is the inspiration and
foundation for this compendium. Dr. Lee, we are privileged to have had this opportunity to
learn from you and count you as a lifelong friend and mentor.
Chapter 1

Oral Cavity, Pharynx, and Larynx Anatomy,

Physiology, and Other Basics

Sagar Kansara, MD
Dennis Kraus, MD
and Patrick Ha, MD

Oral Cavity

Anatomy (see Figure 1) – anatomic space from vermilion border to junction of hard/soft palate
and circumvallate papillae

Figure 1. Oral cavity anatomy.

1. Subsites
a. Vestibule
i. Wet lip

In: Essential Head and Neck Oncology and Surgery ISBN: 979-8-88697-438-6
Editors: Maie A. St. John and Benjamin L. Judson © 2023 Nova Science Publishers, Inc.
2 Sagar Kansara, Dennis Kraus and Patrick Ha

ii. Labial and buccal gingiva and dentition

iii. Buccal mucosa
b. Oral cavity proper
i. Oral tongue-ventral, dorsal, lateral border
ii. Alveolar ridge
iii. Mesial dentition and gingiva
iv. Hard palate
v. Floor of mouth
vi. Retromolar trigone
2. Contents
a. Minor salivary glands – hundreds scattered throughout mucosa, palate, oral
tongue, base of tongue
b. Salivary ducts
i. Parotid duct (Stensen)-lateral to second molars
ii. Wharton’s duct-midline floor of mouth, near the lingual frenulum
c. Dentition − 32 adult teeth, numbered from superior right to superior left (1-
16), inferior left to inferior right (17-32)
d. Oral tongue
i. Papillae − house taste buds, covers surface of anterior 2/3 of tongue
e. Filiform
f. Fungiform
g. Foliate
h. Circumvallate − V shape at the junction of anterior 2/3 and posterior 1/3,
posterior to sulcus terminalis
i. Lingual frenulum − mucosal fold attaching tongue to floor of mouth
and gingiva.
ii. Foramen cecum – see embryology
iii. Lingual tonsil, vallecula – see oropharynx
3. Lymphatic drainage
a. Oral cavity most often drains to level Ia, Ib, IIa, III. Midline structures such
as anterior floor of mouth and tongue tip/posterior tongue often drain
bilaterally.
4. Musculature
a. Extrinsic tongue muscles (CN XII)
i. Genioglossus
ii. Hyoglossus
iii. Styloglossus
iv. Palatoglossus
b. Intrinsic tongue muscles (CN XII)
i. Longitudinal
ii. Vertical
iii. Transverse
c. Floor of mouth musculature
i. Mylohyoid (CN V-nerve to mylohyoid)
ii. Geniohyoid (cervical plexus)
 1. Oral Cavity, Pharynx, and Larynx Anatomy, Physiology, and Other Basics 3

iii. Anterior belly of digastric (CN V)

5. Arterial Supply
a. Lingual artery branches
i. Deep lingual
ii. Dorsal lingual
iii. Sublingual
iv. Suprahyoid
b. Facial artery branches
i. Tonsillar
ii. Labial
iii. Ascending palatine
c. Internal maxillary artery branches
i. Descending palatine artery (via greater and accessory palatine
foramen)
6. Innervation
a. Anterior 2/3 tongue − CN V3 mediates pain, touch, temperature. Taste via
chorda tympani. Lingual nerve -> chorda tympani -> geniculate ganglion ->
nervus intermedius -> nucleus solitarius
b. Greater palatine foramen-transmits descending palatine branch of V2 for
sensory afferents, medial to upper second molar
7. Embryologic origin
a. Fourth week of gestation, 1st-4th pharyngeal arches contribute
b. Tuberculum impar (first arch) joins with lateral lingual swellings to form
anterior 2/3 tongue
c. Hypobranchial eminence develops concurrently to form posterior 1/3
d. Foramen cecum: invagination of the sulcus terminalis, origin of embryologic
thyroid from which it descends into the neck.

Oropharynx
1. Anatomy − hard/soft palate junction to vallecula
2. Subsites
a. Base of tongue (posterior 1/3 of tongue)/lingual tonsil
b. Palatine Tonsil, lateral pharyngeal wall
c. Posterior pharyngeal wall
d. Uvula/soft palate
e. Pharyngoepiglottic and glossoepiglottic folds
f. Vallecula
3. Lymphatic drainage
a. Level IIa, IIb, III, IV, rarely level I
b. Midline structures such as base of tongue drain bilaterally

4. Musculature (via CN X, pharyngeal plexus)

a. Palatoglossus (CN X)
b. Palatopharyngeus (CN X)
4 Sagar Kansara, Dennis Kraus and Patrick Ha

c. Musculus uvulae (CN X)

d. Levator palatini (CN X)
e. Tensor veli palatini (CN V3)
f. Stylopharyngeus (CN IX)
g. Superior constrictor (CN IX/X- pharyngeal plexus)
5. Arterial Supply
a. Lingual artery branches (see oral cavity)
b. Facial artery branches (see oral cavity)
c. Ascending pharyngeal (via tonsillar branch)
d. Maxillary (via descending palatine/tonsillar branch)
6. Innervation
a. Posterior 1/3 tongue- visceral afferents (touch and gag) as well as sensation
via CN IX to nucleus solitarius. Taste (base of tongue and valleculae papillae)
also nucleus solitarius via CN IX.
b. Palate: sensory afferents via nasopalatine and greater palatine nerves (CN V)
7. Embryologic origin
a. Tonsil-second pharyngeal pouch. Tonsillar pillars arise from the second and
third arches. (see Figure 2)

Figure 2. Branchial arch derivatives.

 1. Oral Cavity, Pharynx, and Larynx Anatomy, Physiology, and Other Basics 5

Figure 3. Larynx and pharynx anatomy.

6 Sagar Kansara, Dennis Kraus and Patrick Ha

Larynx and Hypopharynx

1. Anatomy (see Figure 3)-Lingual surface of epiglottis to esophageal inlet and cricoid
a. Supraglottis
i. Epiglottis (supra and infra-hyoid)
• Quadrangular membrane – supporting fibroelastic
membrane, extends from epiglottis to arytenoid/corniculate
• Pre epiglottic space: bounded by hyoepiglottic ligament
superiorly, thyrohyoid membrane anteriorly, epiglottis and
thyroepiglottic ligament posteriorly
ii. Aryepiglottic folds
iii. Arytenoids
iv. False vocal folds
b. Glottis
i. True vocal folds
• Conus elasticus – supporting fibroelastic membrane, extends
from cricoid to merge with vocal ligament
• Reinke’s space – superficial lamina propria of true vocal fold
• Paraglottic space: bounded by thyroid cartilage laterally,
quadrangular membrane superomedially, ventricle medially,
conus elasticus inferomedially, posteriorly by piriform sinus
ii. Anterior commissure
c. Subglottis/trachea
i. Glottis to inferior border of cricoid
d. Hypopharynx
i. Post cricoid space
ii. Piriform sinus
2. Lymphatic drainage
a. Level IIa, IIb, III, IV, VI, VII
b. Supraglottis, post cricoid space, anterior commissure – bilateral nodal
drainage
3. Musculature
a. Laryngeal musculature
i. Intrinsic
• Transverse arytenoid
• Lateral cricoarytenoid
• Posterior cricoarytenoid (only abductor of vocal cord)
• Vocalis/Thyroarytenoid
− Broyle’s tendon – insertion of vocalis tendon to thyroid
cartilage
• Cricothyroid-vocal fold tension-pitch.
ii. Extrinsic
• Suprahyoid musculature
• Infrahyoid musculature
• Stylopharyngeus
• Arterial Supply
 1. Oral Cavity, Pharynx, and Larynx Anatomy, Physiology, and Other Basics 7

− Superior laryngeal artery (via superior thyroid artery-

External carotid) – supraglottis
− Inferior laryngeal artery (via inferior thyroid artery-
thyrocervical trunk) – Glottis and subglottis
4. Innervation
a. Superior laryngeal nerve (CN X) − internal – sensation of supraglottis,
external-motor to cricothyroid
b. Recurrent laryngeal nerve (CN X) − all intrinsic muscles of larynx except for
cricothyroid (via external branch of SLN)
i. Right – loops around subclavian
ii. Left – loops around arch of aorta
iii. Non recurrent nerve more common on the right – can result from
aberrant subclavian artery, resulting in dysphagia lusoria. Rarely can
occur on the left – associated with situs inversus.
c. CN X/pharyngeal plexus – sensation to pharyngeal, esophageal inlet mucosa
5. Embryologic origin (see Figure 2)
a. Supraglottis – third and fourth arch
i. Glottis and subglottis – sixth arch

Physiology
a. Swallow
i. Oral phase
• Mastication - Muscles of mastication (CN V3)
− Pterygoids (medial and lateral)-lateral pterygoid is the
only muscle to protrude and open the jaw
− Masseter
− Temporalis
• Salivation (visceral efferent)
− Parotid gland
o Inferior salivatory nucleus ->
Glossopharyngeal -> Jacobson’s nerve ->
Lesser petrosal nerve (pre ganglionic
parasympathetic) -> Otic ganglion ->
Auriculotemporal nerve to parotid
− Submandibular and sublingual gland
o Superior salivatory nucleus -> nervus
intermedius -> facial nerve -> chorda tympani
(pre ganglionic parasympathetic) ->
submandibular ganglion -> gland
• Control and preparation of bolus via buccinator, palate,
tongue, lips, dentition, orbicularis
ii. Pharyngeal phase-bolus transit from oropharynx through upper esophageal
sphincter into esophagus
8 Sagar Kansara, Dennis Kraus and Patrick Ha

a. Palate elevation (levator/tensor muscles) and posterior movement to

contact posterior pharyngeal wall (Passavant ridge), thus preventing
velopharyngeal insufficiency.
b. Glottic closure, true and false fold as well as arytenoid contraction
c. Hyoid and larynx move superiorly and anteriorly
d. Bolus propulsion via tongue base and constrictor contraction
e. Relaxation of upper esophageal sphincter, cricopharyngeus
iii. Esophageal phase
a. Primary peristalsis and relaxation of lower esophageal sphincter
 1. Oral Cavity, Pharynx, and Larynx Anatomy, Physiology, and Other Basics 9

References

[1] Robbins, J., Hamilton, J. W., Lof, G. L. & Kempster, G. B. Oropharyngeal swallowing in normal adults
of different ages. Gastroenterology 103, 823–829 (1992).
[2] Ferlito, A., Robbins K. T., Shah J. P., Medina J. E., Silver C. E., Al-Tamimi S., Fagan J. J., Paleri V.,
Takes R. P., Bradford C. R., Devaney K. O., Stoeckli S. J., Weber R. S., Bradley P. J., Suárez C.,
Leemans C. R., Coskun H. H., Pitman K. T, Shaha A. R., de Bree R., Hartl D. M., Haigentz Jr M.,
Rodrigo J. P., Hamoir M., Khafif A., Langendijk J. A., Owen R. P., Sanabria A., Strojan P., Vander
Poorten V., Werner J. A., Bień S., Woolgar J. A., Zbären P., Betka J., Folz B. J., Genden E. M., Talmi
Y. P., Strome M., González Botas J. H., Olofsson J., Kowalski L. P., Holmes J. D., Hisa Y., Rinaldo A.
Proposal for a rational classification of neck dissections. Head Neck 33, 445–450 (2011).
[3] Hollingshead, W. Textbook of Anatomy. (Harper and Row, 1974).
Chapter 2

Temporal Bone and Skull Anatomy, Physiology,

and Other Basics

Sujana S. Chandrasekhar, MD
and Hosakere K. Chandrasekhar, MD

Temporal Bone Pneumatization, Bony (Osseous) Anatomy,

and Muscular Attachments

1. The paired temporal bones are located at the lateral skull base in a pyramidal shape
with the base laterally and apex medially and are pneumatized (aerated).
a. The reasons for temporal bone pneumatization are postulated to include:
i. pressure buffer
ii. gas reserve
iii. shock absorption spaces
b. Spaces that are pneumatized are, from laterally to medially:
i. Mastoid – the largest air space in the mastoid is called the antrum
ii. Aditus ad antrum – connection between mastoid and tympanic
cavities
iii. Tympanic cavity (including epitympanum, hypotympanum,
protympanum)
iv. Petrous apex − can be aerated or filled with marrow bone
c. Practice Guideline: Poor pneumatization of the temporal bone correlates with
increased incidence and poor prognosis of: atelectasis, otitis media,
cholesteatoma, and otic capsule injury in temporal bone fracture.
2. The temporal bone is comprised of six different bones:
a. Squamous
i. Is the largest part of the temporal bone, flat and plate-like, located
anterosuperiorly
ii. The external surface of the squamous bone is convex in shape and
this temporal fossa and the lower part of the squamosa are the site of
origin of the temporalis muscle
iii. It articulates superiorly with the parietal bone and anteroinferiorly
with the greater wing of the sphenoid bone

In: Essential Head and Neck Oncology and Surgery ISBN: 979-8-88697-438-6
Editors: Maie A. St. John and Benjamin L. Judson © 2023 Nova Science Publishers, Inc.
12 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

b. Petrous
i. Located posteriorly and medially
ii. Is pyramid-shaped
iii. Contains the inner ear and transmits the internal auditory canal and
carotid artery
c. Mastoid
i. Located posteriorly and laterally
ii. Lateral surface gives attachment to splenius capitis and longissimus
capitis, overlain by sternocleidomastoid.
iii. From the medial surface it gives attachment to the posterior belly of
the digastric muscle
iv. Its inferior portion is the mastoid process, which is absent or
rudimentary at birth and only forms postnatally as the
sternocleidomastoid muscle develops and pulls on the bone.
• Practice Guideline: Because the extratemporal facial nerve is
not protected by the mastoid bone at birth or in early
childhood, it is susceptible to blunt trauma such as forceps
delivery or a minor fall and is susceptible to laceration injury
from a postauricular incision that extends inferiorly.
d. Tympanic
i. Lies inferiorly to the squamous, and anteriorly to the petromastoid
ii. Reversed C-shaped
• Posterior surface goes into the formation of the external
auditory meatus
• Anterior surface forms the posterior wall of the non-articular
mandibular fossa
e. Zygomatic Process
i. Arises from the lower part of the squamous bone
ii. Projects anteriorly, articulating with the temporal process of the
zygomatic bone, to form the zygomatic arch
iii. Posteriorly, it has a downward projection called the articular tubercle,
which is the anterior boundary of the mandibular fossa, the articular
part of the temporomandibular joint (TMJ)
iv. The masseter muscle attaches to the inferior and medial surfaces of
the zygomatic process
f. Styloid Process
i. Located immediately inferior to the opening of the auditory meatus
ii. Acts as an attachment point for muscles and ligaments, such as the
stylopharyngeus muscle and the stylomandibular ligament of the
TMJ
3. The bony external auditory canal is nearly 2 cm long and arises from 4 bones:
a. Its anterior wall and floor and the lower part of its posterior wall are formed
by the tympanic bone
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 13

b. The roof and upper part of the posterior wall are formed by the squamous bone
c. Supero-posterior to the external opening is the suprameatal triangle with the
spine of Henle
d. Its inner end is closed by the tympanic membrane sitting in the bony annulus

External Ear Anatomy and Physiology

1. The external ear comprises the pinna and external auditory canal (EAC). Its function
is to transmit sounds to the tympanic membrane.
2. The external 1/3 of the EAC is cartilaginous; the inner 2/3 is bony (see bony EAC
above). The skin of the canal is thicker in the cartilaginous portion, includes a well-
developed dermis and subcutaneous layer, and contains glands and hair follicles. The
skin lining the osseous portion is thinner, firmly attached to the periosteum, and lacks
a subcutaneous layer.
3. Cerumen is produced by the combination of secretions of two types of glands in the
cartilaginous EAC and serves to clean, lubricate and has a slightly acidic pH that
inhibits bacterial and fungal growth. Cerumen prevents epithelial maceration that can
occur from residual moisture in the ear canal. The two glands and their products are:
a. Sebaceous glands produce sebum
b. Modified apocrine glands produce apocrine sweat
4. Sensory Innervation of the EAC:
a. Greater auricular nerve and lesser occipital nerve (branches of the cervical
plexus) innervate the skin of the auricle
b. Auriculotemporal nerve (branch of the mandibular nerve) innervates the skin
of the auricle and external auditory meatus.
c. Branches of the facial and vagus nerves innervate the deeper aspect of the
auricle and external auditory meatus
i. Practice Guideline 1: the branch of the vagus nerve in the ear canal
is called Arnold’s nerve, nicknamed Alderman’s nerve. Aldermen
(town councilmen) were known to scratch their ear canals with their
pen’s quills in order to stimulate this nerve and set of a coughing fit,
enabling them to leave meetings early.
ii. Practice Guideline 2: an early sign of vestibular schwannoma can be
diminished sensation of the upper outer part of the EAC due to
compression of the facial nerve in the internal auditory canal. This is
called Hitselberger’s sign but it is primarily of historical
significance.
5. Lymphatic Drainage is to the superficial parotid, mastoid, upper deep cervical and
superficial cervical nodes
14 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

Figure 1. Osseous temporal bone anatomy, medial view.

Figure 2. Osseous temporal bone anatomy, lateral view.

Middle Ear Anatomy and Physiology

Overview

The middle ear lies within the temporal bone and extends from the tympanic membrane to
the lateral wall of the inner ear. The main function of the middle ear is to transmit vibrations
from the tympanic membrane to the inner ear via the auditory ossicles. There are two shared
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 15

but relatively distinct spaces: the mesotympanum (middle ear) and the epitympanum (attic).
Subsets of the mesotympanum include the hypotympanum inferiorly and protympanum
anteriorly.

1. Walls of the middle ear:

The middle ear can be visualized as a closed space, with a roof and floor, medial and
lateral walls and anterior and posterior walls.
a. Roof (tegmen tympani) is formed by a thin bone from the petrous part of the
temporal bone. It separates the epitympanic part of the middle ear from the
middle cranial fossa
i. It is contiguous with the roof of the mastoid, also called tegmen
mastoidii or tegmen antrii (for roof of antrum)
b. Floor contains the hypotympanic air cells, beneath which lies a thin layer of
bone over the internal jugular vein (or jugular bulb)
c. Lateral wall is made up of the tympanic membrane - pars tensa is defined by
the tympanic ring and, superiorly, pars flaccida is defined by the notch of
Rivinus
d. Medial wall is formed by the promontory, which is the lateral wall of the otic
capsule (inner ear) and contains a prominent bulge of the horizontal facial
nerve canal and, anteriorly towards the protympanum, the semicanal of the
tensor tympani muscle
e. Anterior wall is a thin bony plate with superior openings for the Eustachian
tube, the tensor tympani muscle and the chorda tympani nerve (iter chordae
anterior). It separates the middle ear from the internal carotid artery
f. Posterior wall (mastoid wall) consists of a lower bony partition between the
tympanic cavity and the mastoid air cells
i. Superiorly, there is an opening in this partition, the aditus ad antrum,
which allows for air flow between the middle ear and mastoid.
ii. Inferiorly, there is a potential space, the facial recess, between the
vertical lie of the facial nerve medially and the chorda tympani nerve
in iter chordae posterior (before it enters the middle ear space).
• Practice Guideline: The facial recess is used surgically to
enhance aeration pathways in canal wall up surgery, to define
the level when taking the canal wall down in chronic ear
disease, or to provide access for implantation of hearing
devices such as cochlear implants and active middle ear
implants.
2. Mucosal lining of the middle ear:
a. The middle ear is lined with squamous and ciliated columnar cells.
b. The posterior mucosal lining is composed of non-secretory flat squamous
epithelium. The number of ciliated columnar epithelial cells in the mucosal
lining progressively increases toward the eustachian tube to constitute about
80% of the cells adjacent to the eustachian tube entrance.
c. These histomorphological changes evidence the progressive transformation
from flat, nonsecretory squamous epithelium to respiratory epithelium that is
16 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

pseudostratified, ciliated columnar cells just proximal to the eustachian tube

entrance.
d. The changing cellular architecture of the middle ear cavity facilitates function
of an organized mucociliary transportation system from primarily the
epitympanum and hypotympanum to the eustachian tube.

Tympanic Membrane

1. The tympanic membrane (TM) is the medial wall of the EAC and lateral wall of the
middle ear. The larger surface area is called the pars flaccida and the smaller, superior,
portion is called the pars tensa. The membranous annulus of the TM sits within the
bony annulus of the tympanic ring and holds the membrane in place to allow for its
vibration in response to sound.
2. Sound vibrations in air are captured by the EAC and cause a movement in the TM
which then creates oscillation of the ossicles. This movement helps to transmit the
sound waves from the tympanic membrane to the oval window at the internal ear.
3. Its diameter is about 8–10 mm and its shape is that of a flattened cone with its apex
directed inward. The ratio of the surface area of the TM to the oval window is 20:1,
and that serves to allow adequate energy transfer between air and the inner ear fluids,
preserving approximately 98% of the sound energy.
4. Structure of the TM is three-fold:
a. The lateral or outer or epithelial layer arises from the first branchial arch
embryologically
b. The middle, fibrous layer, has two layers within it: one circular array and one
radial array of fibers, giving the TM its strength.
i. Practice Guideline: Calcium depositions in the TM are in the fibrous
layer, called myringosclerosis if only involving the TM and
tympanosclerosis if also involving other middle ear structures, and
are secondary to infection and inflammation.
c. The medial or inner or mucosal layer arises from the first branchial pouch
embryologically.
5. Practice Guideline: Congenital cholesteatoma is caused when, in the developing TM,
the lateral (epithelial) layer gets pinched inside into the medial (mucosal) layer as the
first branchial arch and pouch meet. That small ‘knuckle’ of epithelium is then trapped
inside the middle ear and is often seen as a small white ball or pearl just anterior to
the neck of the malleus. It may be missed and only identified after it has grown or
disrupted its sac.

Ossicles

1. The bones of the human middle ear are the malleus (hammer), incus (anvil) and stapes
(stirrup). They are connected via two joints:
a. The incudomallear joint is a synovial joint in the epitympanum between the
head of the malleus and the body of the incus.
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 17

b. The incudostapedial joint is a ball-and-socket synovial joint between the

lenticular process of the incus and the head of the stapes.
2. Malleus has no body; incus has no head; stapes has no neck.
3. The malleus is the largest and most lateral of the ear bones, attaching to the tympanic
membrane, via its handle or manubrium. The head of the malleus lies in the
epitympanic recess, where it articulates with the body of the incus. The inferior most
end of the malleus is the umbo, which is attached to the TM at the apex of its medially-
facing cone.
a. The average weight of the malleus is 23 mg. The average length of the malleus
is 8.23 to 8.53 mm, with 4.72 mm for head and neck and 4.17 mm to 5.20 mm
for the manubrium.
4. The incus consists of a body and two limbs. The body articulates with the head of the
malleus in the attic. The shorter limb is the short process and extends posteriorly from
the body to the aditus ad antrum. The longer limb is the long process which extends
into the posterior middle ear. It ends in a right angle at the small lenticular process of
the incus, which then articulates with the head of the stapes.
a. The average weight of the incus is 27 mg. The average total length (body to
end of long process) of the incus is 7.04 mm. The average width (body to end
of short process) is 5.31 mm. The average length of the long process in 3.27
mm. The average angle between the two limbs of the incus is 97.230.
5. The stapes is the smallest bone in the human body. It is stirrup-shaped, with a head,
two limbs (the anterior and posterior crura), and a base (footplate). The head articulates
with the incus, and the base joins the oval window of the inner ear.
a. The average weight of the stapes is 2.5 mg. Its mean total height is 3.44 mm.
The footplate length is an average of 3.04 mm and its width is 1.10 mm. The
angle between the crura is 51.010.
b. The footplate of the stapes is thicker at the poles (anterior crus (AC) and
posterior crus (PC)) than in the middle.
i. In the normal stapes, the footplate thickness is 0.61 mm at AC,
0.46 mm at the midpoint, and 0.64 mm at the PC.
ii. In a series of patients with otosclerosis, the footplate was
significantly thicker: 0.94 mm at the AC, 0.60 mm at the midpoint,
and 0.72 mm at the PC.
iii. The distance from the udersurface of the footplate to the saccular
membrane is 1 to 1.5 mm.
iv. Practice Guideline: When performing stapes surgery, neither the
instrument used to perforate the footplate nor the prosthesis should
be allowed to enter more than 0.25 mm past the footplate, to minimize
risk of post-stapes surgery sensorineural hearing loss.
6. The malleus and incus arise from the first branchial arch. The stapes arises from the
second branchial arch. The stapes footplate has a dual origin, from the second arch
laterally and the otic capsule medially.
18 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

From: https://simple.wikipedia.org/wiki/Ossicles.

Figure 3. Auditory ossicles.

From: https://emedicine.medscape.com/article/1290547-overview#a2.

Figure 4. Intratemporal course and branches of the facial nerve.

 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 19

Muscles and Nerves in the Temporal Bone

1. Facial Nerve
a. The facial nerve (CN VII) is a mixed nerve with both motor and visceral
components.
i. The motor nerve has its origin in the lower pons and then the fibers
run dorsally to reach the floor of the fourth ventricle, where the fibers
make their first genu (bend) on the surface of the abducens nucleus,
then exit the pons just above the olive and pass laterally toward the
cerebellopontine angle (CPA).
ii. The sensory nerve is called nervus intermedius, originates in the pons
and the medulla and joins the motor portion in the CPA.
b. The facial nerve then enters the internal auditory canal (IAC) and has a
complex course in the temporal bone.
i. In the IAC, CN VII runs in the anterior-superior aspect of the canal
for 10 mm.
ii. Leaving the fundus of the IAC it takes a sharp anterior turn in the
narrow 3mm long labyrinthine segment.
• Practice Guideline: This is the narrowest portion of the
Fallopian canal and the most common site of inflammatory
damage in Bell’s or idiopathic/viral facial paralysis.
iii. At this point the nervus intermedius enlarges into the geniculate
ganglion (GG) and the motor and sensory parts have fused into one
nerve. The GG is the first surgical but second anatomical genu (bend)
of the facial nerve, after which the nerve turns and runs posteriorly.
iv. The nervus intermedius gives off:
• The greater petrosal nerve that sends secretomotor fibers that
join the parasympathetic fibers of the deep petrosal nerve to
become the vidian nerve, pass through the pterygoid canal and
enter the sphenopalatine ganglion. It then innervates five
territories:
1. Nasal septum
2. Lateral nasal wall
3. Hard palate
4. Soft palate
5. Nasopharynx
• The lesser petrosal nerve which gathers the tympanic branch
of CN IX (Jacobson’s nerve) to reach the otic gangion
(attached to V3). From here, secretomotor fibers reach to the
parotid gland.
• Sensory fibers to the posterosuperior EAC and the mucosa of
the contiguous supratonsillar fossa.
• Chorda tympani nerve (see below)
v. In the middle ear, the facial nerve runs horizontally from the GG
anteriorly, crossing the middle ear just superior to the oval window and
20 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

turns inferiorly at the second anatomical genu posteriorly (just inferior to

the horizontal semicircular canal) and then runs vertically down in the
mastoid to exit the bone at the stylomastoid foramen.
• The motor facial nerve gives off:
− In its vertical lie, a branch to the stapedius muscle
− At the stylomastoid foramen, a communicating branch
to the auricular branch of CN X that then gives 3 more
branches to:
o Occipital belly of the occipitofrontalis muscle
o Posterior belly of the digastric muscle
o Posterior belly of the stylohyoid muscle
c. Practice Guideline: When approaching the facial nerve in the middle ear, the
cochleariform process is a useful landmark for the anterior-most extent of the
horizontal facial nerve.
d. Practice Guideline: The Fallopian canal (the bony canal of the facial nerve)
has areas of dehiscence in 20 to 50 percent of cases.
e. Practice Guideline: The most common site of iatrogenic facial nerve injury is
drill trauma at the second genu of the facial nerve. In order to avoid this
catastrophic outcome, the surgeon must be familiar with the relational
anatomy of the short process of the incus, the lateral (horizontal) semicircular
canal, the posterior bony EAC wall, and the facial nerve.
2. Chorda Tympani Nerve
a. The chorda tympani nerve is a branch of the facial nerve (previously
considered a hitchhiker) that joins the lingual nerve, which is the third branch
of the mandibular nerve (V3) to supply secretomotor innervation to salivary
glands in the floor of the mouth and taste to the ipsilateral anterior tongue.
b. It leaves the descending (vertical) facial nerve superior to the stylomastoid
foramen and enters the middle ear posteriorly via the iter chordae posterior. It
then flies between the long processes of the incus and malleus to exit the
middle ear anteriorly at the iter chordae anterior, emerging at the
petrotympanic fissure.
c. Practice Guideline: The chorda tympani nerve is a useful landmark in chronic
otitis media surgery. As it is always medial to the malleus and lateral to the
incus, preservation of the nerve can facilitate safe middle ear surgery even in
the presence of significant inflammation or granulation.
3. Jacobson’s Nerve
a. Jacobson nerve is the tympanic branch of the glossopharyngeal nerve (CN IX)
and arises from the inferior ganglion of the glossopharyngeal nerve. It also
carries preganglionic parasympathetic fibers, from the inferior salivary
nucleus, which eventually enter the otic ganglion.
b. It enters the tympanic cavity via the inferior tympanic canaliculus and
contributes to the tympanic plexus located on the cochlear promontory. The
parasympathetic fibers leave the plexus as the lesser petrosal nerve.
c. Practice Guideline: The neuroendocrine cells related to this nerve give rise
to glomus tympanicum tumors.
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 21

4. Tensor Tympani Muscle

a. The tensor tympani is a striated muscle innervated by the mandibular branch
of the trigeminal nerve (CN V).
b. It attaches from the greater wing of the sphenoid, forms connections with the
bony and cartilaginous Eustachian tube (ET) in its semicanal superiorly and
medially in the ET, passes through the cochleariform process, and inserts onto
the neck of malleus.
c. During contraction, it functions to open the ET and pull the malleus medially,
to stiffen the TM and decreases the propagation of sound throughout the
ossicular chain. However, this is considered inadequate in terms of speed for
noise protection.
5. Stapedius Muscle
a. The stapedius muscle is the smallest skeletal muscle in the body and its tendon
attaches to the stapes, the smallest bone in the body. It is innervated by the
facial nerve (CN VII).
b. The stapedius muscle varies between 9 and 11 mm, with a maximum breadth
of 2-3 mm, and its tendon is about 2 mm long. It begins 3 mm superior to the
stylomastoid foramen and runs medial to midportion of vertical facial nerve.
It ends at the pyramidal process at the posterior wall of the middle ear, where
the tendon attaches to the posterior aspect of the head (capitulum) of the
stapes.
c. Practice Guideline: The acoustic reflex test (ART) is a cranial nerve VII and
VIII reflex arc that can be used to identify otosclerosis (stapes fixation) or for
facial nerve site-of-lesion testing. The reflex arc is likewise considered too
slow for adequate noise protection.

Inner Ear Anatomy and Physiology

1. The inner ear is housed inside the densest bone in the body, the otic capsule. It lies
within the petrous part of the temporal bone. The geometry of the inner ears is precise,
to allow for complex movements that include pitch, yaw and roll.
a. On each side the three semicircular canals (SCCs) are perpendicular to each
other, and the vertical canals (superior and posterior, or anterior and inferior)
are coplanar to the opposite vertical canals of the other side.
b. The horizontal (lateral) SCCs are parallel to the ground with the anterior,
ampullated end 30 degrees higher than the posterior, non-ampullated end.
c. Otolith organs – the utricle is in the same plane as the ipsilateral LSCC; the
saccule is at 90 degrees to that.
d. The neurosensory units within the ampulla of each SCC and in the macules of
the otolith organs also have a strict geometrical orientation.
2. Each bony labyrinth is composed of the cochlea, vestibule and three semicircular
canals. There are five bony openings into the vestibule, as the bony non-ampullated
canals of the superior and posterior canals merge into a common crus (crus commune),
22 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

and it houses the utricle and saccule. The bony labyrinth is lined internally with
periosteum and contains perilymph.
a. Perilymph has a composition similar to cerebrospinal fluid (CSF): rich in
sodium (140mM) and poor in potassium (5mM) and calcium (1.2mM).

Figure 5. Spatial orientation of the semicircular canals.

 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 23

3. The membranous labyrinth lies almost completely within the bony labyrinth. It
consists of the cochlear duct, three semicircular ducts, two otolith organs (utricle and
saccule), and the endolymphatic duct and sac. The sac is outside of the bony labyrinth.
There are six membranous openings into the vestibule (3 ampullated and 3 non-
ampullated ends) per ear. The membranous labyrinth is filled with endolymph.
a. Endolymph has a unique composition: very rich in potassium (150mM), very
poor in sodium (1mM) and almost completely lacking in calcium (20-30 µM).
b. Endolymph has a positive potential (+80mV) compared to perilymph.
4. The inner ear has two openings into the middle ear, both covered by membranes. The
oval window membrane (OWM) lies between the middle ear and the vestibule and
houses the footplate of the stapes. The round window separates the middle ear from
the end of the cochlear duct (scala tympani) and is referred to in older literature as the
‘secondary tympanic membrane.’ The RWM is inside the RW niche, and the RWM
lies perpendicular and inferior to the OWM.
a. Practice Guideline: The electrode array of a cochlear implant can be inserted
directly via an incision in the RWM or via a cochleostomy drilled in the nearby
promontory. All approaches access the basal turn of the cochlea. The bony
overhang of the RW niche often must be drilled away to expose the entire
RWM.
b. Practice Guideline: From a surgical perspective, the cochlea curves to the
right in a left ear and to the left in a right ear. This information is useful when
inserting an electrode with modiolus-facing electrodes.
5. Cochlear microanatomy and physiology
a. Scala vestibuli – contains perilymph
b. Scala media – contains endolymph, organ of Corti
c. Scala tympani – contains perilymph
d. Stria vascularis – produces endolymph and releases it into the cochlea
e. Scala tympani and scala media are separated by the basilar membrane, on
which the organ of Corti sits
f. Scala vestibuli and scala media are separated by Reissner’s membrane
g. Organ of Corti consists of:
i. 3 rows of outer hair cells – for a total of 12,000 per ear
ii. 1 row of inner hair cells – for a total of 3,500 per ear
iii. Inner and outer sulcus supporting cells
iv. Tunnel of Corti
h. Rosenthal’s canal transmits the nerve from the organ of Corti to the ganglion
i. Modiolus – contains the cochlear nerve ganglion
j. The basal turn of the cochlea processes high frequency sounds while the apical
turn processes low frequency sounds.
6. Vestibular neuroepithelial anatomy
a. Semicircular Canals are responsible for angular acceleration and deceleration
i. The vertical SCCs are named either as superior and posterior or
anterior and inferior, in order to emphasize that they are
perpendicular to each other on the same side. The horizontal SCC is
also called the lateral SCC.
ii. The ampullated end of each SCC is its anterior end.
24 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

iii. Hair cells in the vestibular system contain one tall kinocilium and
several stereocilia each.
• Bending the stereocilia toward the kinocilium depolarizes the
cell and results in increased afferent activity.
• Bending the stereocilia away from the kinocilium
hyperpolarizes the cell and results in a decrease in afferent
activity.
iv. There are two types of vestibular hair cells. Type II hair cells are
innervated by bouton terminals of vestibular primary afferents; they
occur in all vertebrates. Type I hair cells are innervated by cup-like,
calyceal terminals; they occur only in amniotes (reptiles, birds, and
mammals). Type I hair cells have significantly higher stereocilia
numbers than type II hair cells.
v. The crista is the sensory epithelial mound in the ampulla that contains
the hair cells. The cupula is a gelatinous matrix that extends from the
hair cell cilia to the opposite side of the SCC wall and is deflected
based on endolymph movement, resulting in either depolarization or
hyperpolarization of the hair cells.
• Type 1 hair cells are more dense at the apex
• Type 2 hair cells are more dense on the slopes
• All hair cells are oriented in the same direction on each crista
vi. Orientation of the kinocilium is towards the utricle (utriculopetal) in
the vertical SCCs and away from the utricle (utriculofugal) in the
horizontal SCCs.
b. Otolithic Organs are responsible for linear acceleration and deceleration and are
gravity receptors
i. The utricle and saccule are the two otolothic organs. The saccule may
also be a rudimentary hearing organ.
ii. They lie perpendicularly to each other and lie within the vestibule
between the SCCs and the cochlea. The saccular membrane is
directly deep to the oval window, about 1 - 1.5 mm away.
• Practice Guideline: In cases of endolymphatic hydrops (ELH),
the saccular membrane can be ballooned out and may, in
cases, touch the undersurface of the stapes footplate. This puts
the inner ear at risk with footplate manipulation. Most stapes
replacement prosthesis enter about 0.25mm into the vestibule.
If contemplating stapedectomy/stapedotomy surgery in
patients with active symptoms of ELH, control the ELH first to
minimize risk of saccular membrane damage from the
drill/pick/laser and prosthesis.
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 25

iii. The macula is the neuroepthelial unit of each otolithic organ. Each
macula is bisected by a central line called the striola. The hair cells
are aligned in relation to the striola: The kinocilia point toward the
striola in the utricle and away from the striola in the saccule. Because
hair cells are oriented in different directions, tilts in any direction will
activate some afferents.
iv. The otolithic membrane is denser than the cupula in the SCCs, and
embedded with calcium carbonate crystals called otoconia. Thus,
with any position of the head, gravity will bend the cilia of some hair
cells, due to the weight of the otoconial membrane which is attached
to the cilia.
• Practice Guideline: Benign paroxysmal positional vertigo
(BPPV) occurs when one or a few otoconia are knocked off of
the otolithic membrane and become free-floating in the
endolymph. In certain head positions, the weight of these
crystals will then move a SSC cupula, causing a sensation of
whirling vertigo that abates only when the head is moved in
the opposite direction, releasing the weight on the cupula.
Because it is the most dependent crista, the posterior SCC is
the site of BPPV in 80% of cases.

Figure 6. Inner ear as gyroscope.

26 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

The Eighth Cranial Nerve

1. CN VIII has two divisions, the anterior cochlear (or acoustic) nerve and the posterior
vestibular nerve. The vestibular portion of CN VIII is further divided into a superior
(SVN) and inferior (IVN) nerve.
a. The SVN innervates the utricle, as well as the superior and lateral SSCs.
b. The IVN innervates the posterior SCC and the saccule.
i. The singular nerve carries information from the posterior SCC crista
and joins the IVN in the internal auditory canal (IAC).
2. Cochlear Nerve: The ganglion of the cochlear nerve is in the modiolus of the cochlea.
a. There are 35,000 neurons in each cochlea.
i. 95% are type 1 neurons which are large, bipolar, and connect with
inner hair cells (IHCs). Each IHC is innervated by 10 to 20 type 1
neurons.
ii. 5% are type 2 neurons which have very small fibers and connect to
outer hair cells (OHCs). Each type 2 neuron innervates several OHCs.
3. Afferent auditory pathways: The orderly spatial arrangement of the cochlear neurons
is maintained in the cochlear nerve trunk and continues into the cochlear nuclei.
a. The nerve fibers from the basal turn (high frequencies) are peripherally
located; those from the apical turn (low frequencies) are in the central region
of the nerve trunk.
b. The fibers end in the cochlear nucleus of the brainstem, mostly to the ventral
cochlear nucleus.
c. Fibers from the dorsal nucleus cross to enter the lateral lemniscus and the on
to the inferior colliculus and then to the medial geniculate body (MGB). Fibers
from the ventral nucleus go to both contralateral and ipsilateral superior olive.
d. Each cochlea has nearly equal bilateral neuronal connections to the MGBs
and thus to the auditory cortices.
4. Efferent cochlear pathways: There are 40,000 efferent cochlear fibers. They originate
as 500-600 crossed and uncrossed fibers as the olivocochlear bundle (of Rasmussen)
in the superior olivary complex. Collaterals go to the ventral cochlear nucleus and
emerge from the brainstem in the IVN. The bundle then joins the cochlear nerve.
Efferent fibers ramify numerously at almost every level before ending on the nerve
chalice of IHCs and on cell bodies of OHCs.
5. Vestibular Nerve: The ganglion of the vestibular nerve is named Scarpa’s ganglion and
lies in the IAC. The SVN and IVN have separate ganglions. There are 18,000
vestibular fibers per ear.
6. Afferent vestibular pathways: Medial to the vestibular ganglion, the SVN and IVN
merge into a single trunk. They end in four major vestibular nuclei: superior, medial,
lateral, and descending, which are in a single oval mass medial to the cochlear nucleus
in the brainstem.
a. Fibers from the maculae reach the medial and lateral vestibular nuclei
b. Fibers from the SCCs reach the superior, medial and lateral vestibular nuclei
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 27

c.Vestibulo-ocular fibers arise from the superior, medial and lateral nuclei, pass
via the medial longitudinal bundle and make connections with the oculomotor
nuclei (CN III, IV and VI).
d. Vestibulo-spinal fibers arise from the lateral, medial and descending nuclei,
reach the anterior horns of the spinal cord, and mediate trunk and limb muscle
reflexes.
7. Efferent vestibular pathways: There are 200-300 efferent vestibular fibers per ear.
They travel with cochlear efferents until meeting up with the IVN and then dispersing
as scattered fibers to supply the maculae and cristae.

Structures of the Vestibular Apparatus. This work by Cenveo is licensed under a Creative Commons
Attribution 3.0 United States (http://creativecommons.org/licenses/by/3.0/us/).
Figure 7. Structural anatomy of the vestibular apparatus.

From: https://www.wikiwand.com/en/Endolymph.
Figure 8. Microanatomical cross-section of the cochlea.
28 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

Figure 9. Neuroepithelial orientation of the ampulla of the semicircular canal.

Figure 10. Neuroepithelial orientation of the maculae of the otolith organs.

Table 1. Comparison of composition of endolymph and perilymph

Composition Perilymph Endolymph

Na (mM) 140 1
K (mM) 4-5 150
Cl (mM) 110 130
Ca (mM) 1.2 0.02
Proteins (g/l) 1 0.15
Glucose (mM) 4 0.5
pH 7.4 7.4
Osmolarity (mosm/l) 290 315
Potential (mV) 0 80
Adapted from Delprat B, Irving S. http://www.cochlea.eu/en/cochlea/cochlear-fluids.
 2. Temporal Bone and Skull Anatomy, Physiology, and Other Basics 29

Questions

1. The auricle and external auditory canal receive sensory innervation from all of the
following nerves EXCEPT:
a. Trigeminal nerve
b. Facial nerve
c. Cochleovestibular nerve
d. Vagus nerve
e. Cervical plexus

2. The heaviest ossicle by weight is the:

a. Malleus
b. Incus
c. Stapes
d. Stapes footplate

3. The most common site of iatrogenic injury to the intratemporal facial nerve is:
a. Geniculate ganglion
b. Horizontal (tympanic) segment
c. Second surgical genu
d. Vertical (mastoid) segment
e. Stylomastoid foramen

4. Which of these pairings is INCORRECT?:

a. Scala vestibuli – perilymph
b. Cupula - crista
c. Scala media – endolymph
d. Macula - striola
e. Scala tympani – endolymph
30 Sujana S. Chandrasekhar and Hosakere K. Chandrasekhar

References

Akazawa Y, Ganaha A, Higa T, Kondo S, Oyakawa Y, Hirakawa H, Suzuki M, Yamashiro T. Measurement of

stapes footplate thickness in otosclerosis by ultra-high-resolution computed tomography. Acta
Otolaryngol. 2020 Nov;140(11):899-903.
Chandrasekhar SS, Chandrasekhar HK, editors. Temporal Bone Histology and Radiology Atlas, Plural
Publishing, 2018.
Delprat B, Irving S. http://www.cochlea.eu/en/cochlea/cochlear-fluids. Accessed 12/4/21.
Gray L. Neuroscience Online, Chapter 10. https://nba.uth.tmc.edu/neuroscience/m/s2/chapter10.html
Reviewed and revised 07 Oct 2020. Accessed 12/4/21.
Kang TK, Ha R, Oh JH, Sunwoo W. The potential protective effects of temporal bone pneumatization: A shock
absorber in temporal bone fracture. PLoS One. 2019;14(5):e0217682. Published 2019 May 31.
doi:10.1371/journal.pone.0217682.
Keidar E, De Jong R, Kwartowitz G. Tensor Tympani Syndrome. [Updated 2021 Jul 25]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK519055/.
Kumar IDV, Chaitanya DK, Singh V, Reddy DS. A morphometric study of human middle ear ossicles in
cadaveric temporal bones of Indian population and a comparative analysis. J Anatom Soc India 2018;
67:12-17.
Massa HM, Lim DJ, Kurono Y, Cripps AW. Middle Ear and Eustachian Tube Mucosal Immunology. Mucosal
Immunology. 2015;1923-1942. doi:10.1016/B978-0-12-415847-4.00101-4.
Mogra K, Gupta S, Chauhan S, Panwar L, Rajuram. Morphological and morphometric variations of malleus in
human cadavers. Int J Healthcare Biomed Res. Apr 2014;2(3):186-192.
Moravec WJ, Peterson EH. Differences Between Stereocilia Numbers on Type I and Type II Vestibular Hair
Cells. J Neurophys Nov 2004;92(5):3153-3160. https://doi.org/10.1152/jn.00428.2004.
Prasad KC, Azeem Mohiyuddin SM, Anjali PK, Harshita TR, Indu Varsha G, Brindha HS. Microsurgical
Anatomy of Stapedius Muscle: Anatomy Revisited, Redefined with Potential Impact in Surgeries. Indian
J Otolaryngol Head Neck Surg. 2019;71(1):14-18. doi:10.1007/s12070-018-1510-5.
Rask-Andersen H, Schart-Moren N, Stromback K, Linthicum F, Li H. Special anatomic considerations in
otosclerosis surgery. Otolaryngol Clin NA. April 2018, 51(2):357-374.
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secretions. J Am Acad Audiol. 1997 Dec;8(6):391-400. PMID: 9433685.
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Philadelphia, 1986.
Chapter 3

Neck Spaces and Fascial Planes

Omar A. Karadaghy, MSCI, MD

Mia Jusufbegovic, MD
Jeffrey M. Blumberg, MD, FACS
and Yelizaveta Shnayder, MD, FACS

Objectives

1. To describe the anatomy of the neck allowing for enhanced understanding of the
pathophysiology of deep space neck infections and pathology.
2. To succinctly describe the anatomic boundaries and relationships of key cervical
structures with the aid of supplemental illustrations.
3. To understand the anatomic boundaries and spaces of the neck as they relate to surgical
management of both benign and malignant pathology of the head and neck via
transoral and transcervical approaches.

Introduction

1. Comprehension of complex head and neck anatomy is imperative for understanding

the etiology and management of diseases affecting this region.
2. Pathophysiology of deep space neck infections and its potential propagation to
adjacent regions such as the mediastinal or intracranial regions require a foundational
understanding of the subunits within the neck.
3. Knowledge of important structures of the head and neck is necessary to reduce
morbidity when surgical intervention is required.

Anatomy

1. Triangles of the Neck

a. Anterior Cervical Triangle
i. Formed by the mandible, the sternocleidomastoid muscle (SCM), and
the midline

In: Essential Head and Neck Oncology and Surgery ISBN: 979-8-88697-438-6
Editors: Maie A. St. John and Benjamin L. Judson © 2023 Nova Science Publishers, Inc.
32 Omar A. Karadaghy, Mia Jusufbegovic, Jeffrey M. Blumberg et al.

ii. Further subdivided into the digastric, carotid, muscular and submental
triangles
• Digastric (Submaxillary) Triangle
− Formed by mandible, anterior belly and posterior belly
of the digastric muscle
• Carotid Triangle
− Formed by posterior belly of digastric, superior belly of
omohyoid, and SCM
• Muscular Triangle
− Formed by superior belly of omohyoid, midline, and
SCM
• Submental Triangle
− Formed by hyoid, mandible, and bilateral anterior
bellies of digastric muscles
− Posterior Cervical Triangle
iii. Formed by SCM, trapezius, and clavicle
iv. Further subdivided into the occipital and subclavian triangles
• Occipital Triangle
− Formed by SCM, trapezius, and omohyoid
• Subclavian Triangle
− Formed by omohyoid, SCM, and clavicle
2. Levels of the Neck (Figure 1)
a. Level I
i. Level Ia
• Submental lymph nodes
• Midline structure

Figure 1. Levels of the neck.

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