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Dr. Supreet Singh Nayyar, AFMC 2012

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Cholesteatoma (Part II) Relevant Anatomy

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Folds & Ligaments of Middle Ear

Mucosal folds (Toss)

Lateral incudal fold Superior incudal fold Medial incudal fold Interossicular fold Ant malleolar fold Posterior malleolar fold Superior malleolar fold Lateral malleolar fold Tensor tympani fold Stapedial fold Obturator fold

Ligaments

Superior incudal ligament Posterior incudal ligament Ant malleolar ligament Post malleolar ligament Sup malleolar ligament

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Dr. Supreet Singh Nayyar, AFMC 2012

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Development of mucosal folds

Saccus anticus Ant pouch von troltsch Supra tubal recess

Saccus medius Ant saccule Ant attic Middle saccule Sup incudal space

Prussacks space Post saccule Pars petrosa

Saccus superior Post pouch of von troltsch Inf incudal space Pyramid Post isthmus Pars squamosa

Saccus posticus Round window niche Sinus tympani Oval window

Prussacks space anatomy (Toss)

Laterally pars flaccida Medially neck of malleus Superiorly lateral malleolar fold Inferiorly lat process of malleus Anterior boundary ant malleolar fold & ligament arising from the neck of malleus Posterior boundary post malleolar fold & ligament arising from neck of malleus Connected to post pouch of von troltsch by small gap b/w post malleolar fold &

fibrous annulus

Ant isthmus b/w tensor tympani fold & ant crura of stapes

Post isthmuslocated near tip of short process of incus, b/w post incudal ligament ,

medial incudal fold, pyramid & stapedius ms.

Ant pouch von troltschb/w ant malleolar fold & tympanic membrane ant to handle of

malleus

Post pouch von troltsch b/w post malleolar fold & tympanic membrane posterior to

handle of malleus

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Dr. Supreet Singh Nayyar, AFMC 2012

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Division of posterior wall of middle ear

Types of cholesteatoma

Posterior Epitympanic cholesteatomao Originates in prussacks spaceo Lies lateral to ossicleso Go via superior incudal space to aditus & antrum (middle saccule

of saccus medius)

o Spreads to mesotympanum via posterior pouch of von troltsch ( fromwhere it goes to inf incudal space) (saccus superioris)

Posterior mesotympanic cholesteatoma (saccus posticus)o Originates in postero superior quadrant of pars tensao Lies medial to ossicleso Spreads to involve facial recess & sinus tympanio Reaches mastoid via posterior tympanic isthmus

Anterior epitympanic cholesteatoma (saccus anticus)o Formed from epitympanic retraction anterior to head of malleuso Reaches mesotympanum via ant pouch of von troltscho May involve supra tubal recesso Geniculate ganglion at risk

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pyramid

Facial

recess

Lateral

tympanic

sinus

Post

Tympanic

sinus

Sinus

Tympani

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