Possible clinical implications of the structural variations between the tympanic membrane quadrants

Firas Kassem, Or Dagan, Ameen Biadsee, Muhamed Masalha, Ariela Nachmani, Ben Nageris, Daniel J. Lee, Omer J. Ungar*, Ophir Handzel

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Introduction: Retraction pockets and marginal perforations of the pars tensa of the tympanic membrane (TM) are most commonly found at superior posterior quadrant (SPQ). The patulous Eustachian tube tends to manifest in the same quadrant. Variation in the structure of the TM may explain these observations. Material and Methods: A line defined by the manubrium was used to divide the pars tensa into anterior and posterior portions. A transverse line centered on the umbo divides the pars tensa into superior and inferior parts, resulting in four quadrants. Surface areas of each of the TM quadrants were measured in a sample of 23 human adult formalin-fixed temporal bones. The TMs were completely excised, faced medially, and placed against graph paper to maintain scale measurements, photoed, and measured. TM thickness was measured on a different set of 20 human temporal bones (TB) preparations with normal external and middle ears. Four random loci were chosen from each pars tensa's TM quadrant. The thickness was measured using high-magnification power microscopy. Results: The SPQ was the largest and thinnest of the four quadrants. It occupies 31% of the pars tensa area. It is 69 μm as compared to approximately 85 μm in the other quadrants. The radial lines between the umbo and the annulus are in descending order from superior posterior toward the anterior-superior radials. Conclusion: The SPQ has the largest vibratory area and is the thinnest of the four TM quadrants. Variation in the thickness of the middle, fibrous layer accounts for the variation in the thickness of the TM. These findings may explain the tendency of pathologies related to Eustachian tube dysfunction to preferentially manifest in or originate from the SPQ.

Original languageEnglish
Pages (from-to)1164-1170
Number of pages7
JournalLaryngoscope investigative otolaryngology
Issue number4
StatePublished - Aug 2022


  • Eustachian tube dysfunction
  • tympanic membrane area and thickness
  • tympanic membrane quadrants


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