1.

Anatomic/histologic differences between the outer and inner portions of the

External Ear Canal?
The external ear canal can be divided into an outer and an inner portion,
where the outer cartilaginous portion occupies 1/3 and the inner bony portion 2/3 of
the total length of the canal. The cartilaginous section of the external canal is
angled postero-superiorly, while the bony canal is inclined antero-inferiorly. This
gives the ear its characteristic s-shape course. The outer third of the canal has an
incomplete cylinder of cartilage which is deficient in its superior position but bridged
by dense fibrous tissue attached to the squamous portion of the temporal bone. It is
continuous with the conchal and tragal cartilage laterally, attached to the bony
canal wall medially, with the fissures of Santorini found at the antero-inferior portion
of the canal. On the other hand, the bony canal is made of a complete cylinder
extending laterally from the ear drum. The tympanic portion of the temporal bone is
found at the anterior and inferior walls, while the squamous and mastoid portions of
the temporal bone are at the superior and posterior walls.
2. Feature/s in the anatomy of the external ear canal makes otoscopic examination
difficult or easy?
It is usually difficult to look at the posterior inferior portion of the ear drum due to
the angle of the membrane within the canal. The cartilaginous and the bony portion
of the external ear are oriented differently, thus the ear has an s-shaped course.
Pulling on the pinna backwards and upwards can partly straighten the canal on
adults and horizontally backwards on infants. In small children, the angle of the
drum is different, with the top of the drum appearing more lateral than the inferior
part. This makes viewing easier since the canal is straighter than adults.
3. Trace the anatomy of the normal hearing pathway. What structures are involved
(in correct order) from peripheral to central?
The external ear receives the sound waves and funnels them (direct and reflected)
to the external auditory meatus. From the meatus, the external auditory canal
passes inward to the tympanic membrane. The tympanic membrane moves in and
out, thus displaces the stapes and the oval window. As the stapes moves outward,
the oval window moves outward as well, decreasing the pressure in the scala
vestibuli. The round window, on the other hand, moves inward due to the
incompressible perilymph that fills the scala vestibuli and the rigid bone structure of
the cochlea. The scala vestibuli pressure falls below scala tympani pressure, thus it
pulls up the incompressible scala media, which in turn causes the basilar membrane
(and the organ of Corti) to bow upward. Afterwards, the organ of Corti creates a
shear force between the hair bundle of the outer hair cells and the attached
tectorial membrane. The hair bundles of the outer hair cells now tilt toward their
longer sterevilli. This results to the depolarization of the outer hair cells and the
consequential contraction of the motor protein prestin and the outer hair cells. This

contraction of the outer hair cells accentuated the upward movement of the basilar
membrane. Endolymph would now be forced to flow out of the inner sulcus, beneath
the tectorial membrane, towards its tip. Because of this, the inner hair cell bundles
bend toward the longer stereovilli, opening the transduction channels and resulting
to depolarization to open voltage-gate Ca2+ channels. The synaptic vesicles would
now fuse to release glutamate, triggering the action potential in afferent neurons
that relays the auditory signals to the brainstem. The cell bodies of the afferent
neuron of the cochlear lie within the spiral ganglion, which corkscrews up around
the axis of the cochlea. The cochlear nerve would now split into 3 as it enters the
cochlear nucleus. Lastly, the cochlear nucleus would project to the brainstem,
midbrain, thalamus, and the auditory cortex to decipher the sound heard.
From peripheral to central, the structures involved are the ear, auditory
nerve, spiral ganglion, neural pathways, and the auditory cortex.
4. What part of the hearing mechanism is stimulated when Weber test is performed?
The Weber Test stimulates the bone conduction or the stimulation of the inner
ear through the middle ear ossicles.
5. What anatomic structures in the nasal cavity make visualization/examination
inside difficult?
The nasal membrane usually swells, thus a decongestant is usually sprayed
before an examination to permit easy passage. Only the vestibule, the anterior
portion of the septum, and the lower and middle turbinates can be observed
through the otoscope. Examination of the posterior abnormalities may be done
through the use of a nasopharngeal mirror or endoscopy. In cases of deviated
septums or enlarged turbinates, there is also a difficulty in examining the deeper
part of the nasal cavity.
6. How will you facilitate better visualization of the oropharnygeal structures?
Maximal opening of the oral cavity provides better visualization of the
oropharyngeal structures. If the patient is wearing dentures, the physician can offer
a paper towel and ask the patient to remove them so the mucosa underneath can
be examined. With the use of a good light and the help of a tongue blade, the oral
mucosa can be properly examined. The tongue and the floor of the mouth can be
properly examined by asking the patient to put out his or her tongue. Palpation for
any lesion is performed by grasping the tip of the tongue of the patient with a
square of gauze, wearing proper gloves, and palpating the sides of the tongue. To
view the pharynx, let the patient open his or her mouth, with the tongue not
protruding, and ask him or her to say ah or yawn. If not, a tongue blade may be
used to firmly press down on the midpoint of the arched tongue. It should be far
enough to visualize the pharynx but not so far that it causes gagging.

7. What are important surface landmarks (at least 5) in the neck to serve as
reference points in performing a good neck examination (inspection, palpation,
auscultation)?
The mandible, trapezius muscle, clavicle, cricoid cartilage, and the
sternomastoid muscle.