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salivary gland disorders. The tympanic nerve remains
clinically relevant to the modern otolaryngologist and as
such a detailed understanding of its anatomy is crucial.
© 2014 Baishideng Publishing Group Inc. All rights reserved.
Key words: Tympa n i c ne r v e ; C a n a l icul u s ; G l o s s opha -
ryngeal nerve; Promontory
Core tip: The tympanic nerve is the first branch aris-
ing from the inferior ganglion of the glossopharyngeal
nerve. Despite its modest size it has a multitude of
functions which are not only limited to the middle ear.
In this review we detail the clinical anatomy of the tym-
panic nerve and its surgical applications in Otolaryngol-
ogy as they have evolved over the years. We also pro-
vide a brief summary of the life and achievements of
the indefatigable Ludwig Levin Jacobson, an anatomist
and military surgeon, who is credited with the discovery
of the tympanic nerve.
Kanzara T, Hall A, Virk JS, Leung B, Singh A. Clini-
cal anatomy of the tympanic nerve: A review. World J
Otorhinolaryngol 2014; 4(4): 17-22 Available from: URL:
http://www.wjgnet.com/2218-6247/full/v4/i4/17.htm DOI: http://
dx.doi.org/10.5319/wjo.v4.i4.17
INTRODUCTION
This review describes the present evidence outlining the
anatomy, function and surgical significance of the tym-
panic nerve.
The tympanic nerve arises from the inferior ganglion
of the glossopharyngeal nerve traversing through the
tympanic canaliculus into the middle ear. On the prom-
ontory it coalesces with sympathetic fibres from the
carotid chain forming the tympanic plexus. Functionally,
it provides somatic fibres to the middle ear as well as
parasympathetic fibres to the parotid gland via the lesser
petrosal nerve.
Clinical anatomy of the tympanic nerve: A review
Todd Kanzara, Andy Hall, Jagdeep Singh Virk, Billy Leung, Arvind Singh
Todd Kanz ara , Department of Surgery, Lister Hospital, Coreys
Mill Lane, Stevenage, Hertfordshire SG1 4AB, United Kingdom
Andy Hall, Arvind Singh, Department of ENT, Harrow, Middle-
sex HA1 3UJ, United Kingdom
Jagdeep Singh Virk, Department of ENT, Queens Hospital,
Romford RM7 0AG, United Kingdom
Billy Leung, Department of Anatomy, Kings College, Guys Cam-
pus, London SE1 4XA, United Kingdom
Author contributions: Kanzara T, Hall A, Virk JS, Leung B and
Singh A all contributed equally to this review; Kanzara T and
Hall A conceptualised, designed and drafted the manuscript; Virk
JS and Leung B assisted with data acquisition, literature search
and analysis; Singh A provided senior supervision data analysis
and made critical revisions; all authors reviewed and approved
thenalmanuscriptassubmitted.
Correspondence to: Dr. Todd Kanzara, Department of Sur-
gery, Lister Hospital, Coreys Mill Lane, Stevenage, Hertfordshire
SG1 4AB, United Kingdom. todd.kanzara@nhs.net
Telephone: +44-779-6945100 Fax: +44-170-7224373
Received: July 7, 2014 Revised: August 7, 2014
Accepted: September 4, 2014
Published online: November 28, 2014
Abstract
The tympanic (Jacobson’s) nerve is a useful anatomi-
cal structure in the middle ear with both practical and
physiological functions extending beyond its origin.
The paper reviews its clinical anatomy in adults and
itssurgicalsignicance.Englishlanguagearticlesfrom
5 major databases and Google scholar search engine
were used to identify papers outlining the anatomy of
the tympanic nerve, associated pathology and surgical
relevance. In the majority of cases the tympanic nerve
arises from the inferior ganglion of the glossopharyn-
geal nerve traversing through the tympanic canaliculus
into the middle ear. On the promontory it coalesces
withsympatheticbresfromthecarotidchainforming
the tympanic plexus which has individual variability.
Functionally,aswellasgivingoffparasympatheticbres
to the parotid gland
via
the lesser petrosal nerve, it is a
useful anatomical landmark for cochlear implantation.
The surgical importance of the tympanic nerve is not
only restricted to middle ear surgery; it also extends to
REVIEW
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World Journal of
Otorhinolaryngology
W J O
Submit a Manuscript: http://www.wjgnet.com/esps/
Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx
DOI: 10.5319/wjo.v4.i4.17
World J Otorhinolaryngol 2014 November 28; 4(4): 17-22
ISSN 2218-6247 (online)
© 2014 Baishideng Publishing Group Inc. All rights reserved.
17
We have summarised the anatomy from its origin
and traced its course through the relevant anatomical
segments namely extra tympanic; hypotympanic; and
intratympanic. We also elucidate its role in middle ear in-
nervation and secretomotor supply to the parotid. The
surgical relevance of the tympanic nerve and the relevant
pathological processes are also covered in detail. Further,
we have detailed, a historical perspective on the intriguing
life of Ludwig Levin Jacobson who is credited with the
discovery of the tympanic nerve. For clarity we will use
the term tympanic nerve throughout the article although
the term “Jacobson’s nerve” is used synonymously
throughout the literature.
SEARCH STRATEGY
We cond uct ed a s yst ema ti c rev iew usi ng Pu bme d, M ed -
line, Embase, Google Scholar, Web of Science and
the Cochrane library in January 2014. Databases were
searched using the term “Jacobson’s/tympanic nerve”
before exploring the relevant subheadings. Results were
limited to articles published in English. The abstracts
were reviewed and most relevant selected for inclusion.
Citation links were hand searched to identify further ar-
ticles of relevance.
DISCOVERY OF THE TYMPANIC NERVE:
ROLE OF LUDWIG LEVIN JACOBSON
Ludwig Levin Jacobson was born in Copenhagen on 10th
January 1783 to a family of jewellers[1]. After attending
a German school in Stockholm he returned to surgical
training in Copenhagen[1,2]. His interests included human
anatomy, zoology, chemistry and teaching. He is credited
with various anatomical discoveries in animals and most
importantly in humans[1,2]. As early as 1809 he discovered
a previously undetected vomeronasal organ found in the
nasal cavities of mammals only fully understood over a
hundred years after his death[2]. In 1813 he would first
describe the tympanic nerve outlining its anatomical rela-
tions and physiological function[1,2]. Later he also detailed
the anatomy and function of Jacobson’s canaliculus (tym-
panic canaliculus) and “Jacobson anastomosis” plexus
(tympanic plexus)[1]. By the time of his death in 1843 he
had become a Professor and the King’s personal physi-
cian[1].
ORIGINS AND EXTRA-TYMPANIC
SEGMENT
The tympanic nerve is the first branch arising from the
inferior ganglion (petrous ganglion) of the glossopharyn-
geal nerve as it exits the jugular foramen[3-5] (Figure 1).
Anatomical variations of its origin are rarely reported.
Historically Arnold, cited by Donaldson, noted that the
tympanic nerve may occasionally arise at a higher point
than the inferior ganglion of the glossopharyngeal nerve
and Cuvellier, also cited by Donaldson, suggested that it
could arise from contributions from both cranial nerves
IX and X[6]. These findings have not been supported by
more recent studies.
The anatomical study of the tympanic nerve by Tek-
demir et al[7] using ninety-six cadaveric temporal bones
states that it arises from the inferior ganglion which is lo-
cated at a mean distance of 11.3 mm from the genu (knee
like bend). It invariably angulates at 90 degrees inferior to
the genu en route to the tympanic canaliculus[7].
The tympanic nerve and the inferior tympanic artery
enter the inferior tympanic canaliculus, a bony septum
that lies between the internal carotid foramen medially
and the internal jugular foramen laterally[8] (Figure 2).
The tympanic canaliculus is located medial to the styloid
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Kanzara T
et al
. Anatomy of the tympanic nerve
18
Chorda tympani
Facial nerve
Semicircular canals
ICA (C6)
Glossopharyngeal
nerve
Vagus nerve
Inferior ganglion
Accessory nerve
Jacobson’s nerve
Hypoglossal nerve
Figure 1 Image demonstrating the path of the glossopha-
ryngeal nerve and the origin of the tympanic/Jacobson’s
nerve (arrow) at the inferior ganglion (arrowhead). (Used
with permission from Dr. Takanori Fukushima, Professor of
Neurosurgery, Duke University Medical Centre and Duke Ra-
leigh Hospital). ICA: Internal Carotid artery.
process and the stylomastoid foramen[9]. In the tympanic
canaliculus, the tympanic nerve traverses superiorly on
the medial wall of the middle ear onto the cochlea prom-
ontory[6]. The auricular branch of the superior ganglion
of the vagus nerve (Arnold’s nerve) courses 1-2 mm lat-
eral to the tympanic nerve[9,10].
The mean length of the tympanic canaliculus is 9.5 mm
and the inferior 2/3 of the tympanic canaliculus follows a
vertical course whilst the superior 1/3 courses anteromedi-
ally at an angle between 160 and 170 degrees[7]. In the study
by Tekdemir et al[7], the external opening of the tympanic
canaliculus was located inside the petrosal fossula, the
depression on the inferior surface of the petrous portion
of the temporal bone between the jugular fossa and the
carotid canal opening in 80% of cases. In the 20% of the
cases where the fossula was not identifiable, the opening
was found on the anterolateral aspect of the jugular bulb[7].
Porto et al[3] (20 specimens) and Tekdemir et al[7] (96
specimens) both reported findings of the tympanic nerve
being covered in bone in its entire course in 5% and 20%
of their specimens respectively. Donaldson, in a study
of 50 temporal bones, observed that in 6% of the speci-
mens the tympanic nerve ran part or its entire middle ear
course deep to the bone of the middle ear and that in
these cases there was no hypotympanic branch[6].
An aberrant course of the tympanic nerve where it
coursed anteromedially within the bony septum before
entering the middle ear anteriorly accompanied by the
sympathetic branch from the internal carotid sympathetic
plexus was reported in one of the specimens in the same
study[6]. Another unusual finding was a unilateral duplica-
tion of the tympanic nerve[6].
INTRATYMPANIC AND HYPOTYMPANIC
COURSE
The tympanic nerve emerges on the promontory of the
middle ear, on its medial wall and anterior to the round
window[3]. It exits through the internal aperture of the
tympanic canaliculus which lies anterior to the inferior
half of the round window[7]. The nerve divides on the
promontory forming an anterior branch which courses
up towards the Eustachian tube and a posterior branch
that skirts the rim of the round window[11,12]. The two
divisions of the tympanic nerve are often found running
parallel to each other on the promontory[13]. On aver-
age the distance between Jacobson’s nerve and the lip of
round window niche is 2.1 mm with a range of zero to
3.2 mm[14]. A study of 82 temporal bones demonstrated
that if the main trunk of the tympanic nerve is visible
on the promontory it can be concluded with 95 per cent
certainty that it is within 3.3 mm of the lip of the round
window niche[14].
Hypotympanic branches are common and therefore
an important consideration in surgery of the tympanic
nerve. One of the earliest observations on the anatomy
of the tympanic nerve suggested that in 40% of cases
a hypotympanic branch arises from the main trunk and
runs anteriorly and below the promontory to connect to
the pharyngotympanic tube recess[15]. Later studies sug-
gests a slightly higher preponderance of a hypotympanic
branch of the tympanic nerve, i.e., 50% and 48%, albeit
with a variable distribution[3,6]. The hypotympanic branch
can have occasional single or double divisions[3,6]. It is
reportedly narrower in diameter coursing anterosupe-
riorly in approximately 45% of cases and posteriorly in
5%[3]. The presence of a hypotympanic branch correlates
strongly with the main trunk of the tympanic nerve be-
ing covered by promontory bone for the majority of its
course, only surfacing on the promontory for 1-2 mm[3].
Interestingly, two canaliculi with nerves passing over the
promontory have been reported[6].
On the promontory, the tympanic nerve coalesces
with the superior and inferior caroticotympanic nerves
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Zygomatic process
Articular tubercle
Tympanic part
Digastric groove
Mastoid part
Styloid process
Juglar fossa
Stylomastoid foramen
Carotid foramen
Tympanic canaliculus
Figure 2 Illustration of the temporal bone dem-
onstrating the relationship between the tympanic
canaliculus, the carotid foramen and the jugular
fossa.
Kanzara T
et al
. Anatomy of the tympanic nerve
which branch from the carotid plexus to form the tym-
panic plexus[16-18] (Figure 3).
Even though the tympanic nerve and plexus can be
found in open grooves (submucosally) on the promon-
tory, in approximately 20% of cases its branches are hid-
den in bony canals of varying depth making it difficult
to locate[18]. Additionally, the nerve and plexus exhibit
a multitude of variations as to course, branching and
anastomoses. In fact there is no bilateral symmetry; each
plexus is unique[18].
The tympanic nerve has a close anatomical relation-
ship with the cochlea; it extends superiorly directly under-
neath the cochleariform process[19]. Furthermore, it acts
as a useful marker in identifying the anterior and poste-
rior parts of the basal segment of the scala tympani of
particular relevance in cochlear implantation[8,14,20]. Both
segments are in close relation to the hypotympanic cells,
infralabyrinthine cell tracts and the jugular bulb[8,14]. The
preganglionic parasympathetic fibres reconstitute posteri-
orly to the cochleariform process, eventually lying medial
to it coursing superiorly across the promontory towards
the geniculate ganglion of the facial nerve[8].
The tympanic nerve exits the middle ear through its
own canal below the tensor tympani muscle or through
the canal for the tensor tympani muscle as the lesser su-
perficial petrosal nerve[20]. From the anterior surface of
the temporal bone the lesser superficial petrosal nerve ex-
its the middle cranial fossa via foramen ovale or the emis-
sary sphenoidal foramen (canal of Vesalius) en route to
the otic ganglion conveying presynaptic parasympathetic
fibres[21]. The post ganglionic fibres travel with the auricu-
lotemporal nerve, a sensory branch of the mandibular
division of the trigeminal nerve to provide the parasym-
pathetic innervation of the parotid gland[11] (Figure 4).
FUNCTION
In addition to conveying parasympathetic fibres to the
parotid, the tympanic nerve provides somatic fibres to
the tympanic cavity: the medial wall of the tympanic
membrane, mastoid air cells and the Eustachian tube[8,22].
Animal studies suggest that the tympanic nerve plays
an important role in the regulation of middle ear pres-
sure[23,24]. Eden et al[23,24] demonstrated the existence of
a neural pathway between the tympanic plexus and the
pons and the presence of efferent fibres connecting the
pons and the Eustachian tube. The deduction from these
studies was that the glomus bodies located along the
tympanic nerve, in concert with other structures, sense
changes in middle ear pressure[24]. These changes are in
turn conducted to the pons via the tympanic nerve result-
ing in a feedback loop thereby regulating middle ear pres-
sure[23,24]. Songu et al[25] in an attempt to replicate these
findings in humans demonstrated, albeit inconclusively,
that the tympanic plexus might play a more significant
role in the regulation of middle ear pressure via the Eu-
stachian tube than had been previously thought. Such
findings are encouraging and more studies of this nature
are required given that Eustachian tube dysfunction and
its sequelae remains a difficult condition to manage with-
in otolaryngology.
PATHOLOGY
The tympanic nerve is covered in bone for most of its
course and is unlikely to be damaged in trauma; injury
would indicate severe force[26]. The nerve can be involved
in non-traumatic pathological processes along its course,
particularly within the foramen[9]. Glomus jugulare tu-
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Stapes
Mastoid cells
Facial nerve [Ⅶ]
Posterior
Stylomastoid foramen
Round window
Jugular foramen Promontry
Tympanic plexus
Lesser petrosal nerve
Tensor tympani muscle
Caroticotympanic nerve
(branch from internal carotid artery)
Pharyngotympanic tube
Carotid foramen
Tympanic nerve (nerve of Jacobson)
Tympanic canaliculus
Inferior ganglion of glossopharyngeal nerve [IX]
Anterior
Figure 3 Schematic illustration of demonstrating the tympanic nerve from its origin (shaded in black), its course and its anatomical relations within the
right middle ear.
Kanzara T
et al
. Anatomy of the tympanic nerve
mours, which tend to be slow growing in nature, are the
commonest tumour found in the jugular foramen[9]. They
have a preponderance to form along the tympanic and
Arnold’s nerves as well as in the adventitia of the internal
jugular vein[9,27]. In advanced stages they tend to be mul-
tidirectional in growth and owing to the narrowness of
the jugular foramen may expand and erode to into cranial
nerves IX to XII[9].
Tym panic nerve schwa nnoma s have been reported
but are still rare[9,27]. They are Schwann cell derived tu-
mours which arise intracranially and then extend infe-
riorly along the jugular foramen[27]. Pressure erosion is
common in patients with jugular foramen schwannomas
but rare in glomus jugulare tumours where bony erosion
is common[9].
Post-surgical traumatic neuromas of Jacobson’s nerve
have been reported, usually occurring in the context of
previous middle ear surgery where the tympanic nerve is
damaged or severed (intentionally or otherwise) leading
to formation of neuromas from nerve growth around
the amputated stump, leading to recurrent otalgia[28].
SURGICAL RELEVANCE IN
OTOLARYNGOLOGY
Lempert first described tympanic plexus ablation for the
relief of tinnitus in 1946, referring to it as tympanosym-
pathectomy[29]. Clinical use of the procedure faltered ow-
ing to unsatisfactory results. Hemenway later suggested
interruption of the efferent neuronal pathway at the level
of the middle ear by sectioning the tympanic nerve as a
theoretical approach to the management of Frey’s syn-
drome[30]. However, the procedure was later popularised
by Golding-Wood who used it for the successful treat-
ment of Frey’s syndrome coining the term tympanic neu-
rectomy to describe it[31]. In addition to the management
of Frey’s syndrome, Golding-Wood postulated other in-
dications for the procedure notably, paradoxical gustatory
lacrimal reflex “crocodile tearing” and chronic secretory
otitis media although these have no indication in mod-
ern clinical practise[21]. Tympanic neurectomy has been
considered useful in the management of otalgia with the
proviso that other important causes of otalgia have been
excluded[22].
Later Friedman added other important indications
for tympanic neurectomy including parotid duct stenosis,
salivary duct dilation (sialectasis) and parotid salivary fis-
tula[21].
Owing to the potential serious complications of
parotidectomy, duct ligation or radiotherapy as alterna-
tive forms of treatment for these conditions, tympanic
neurectomy can be undertaken with little morbidity or
operative discomfort[17]. A case series of ten patients for
parotid sialectasis managed with tympanic neurectomy
in the United Kingdom by Daud et al[17] demonstrated
symptom alleviation in seven patients and as such is ad-
vocated by the authors as a first-line surgical procedure
for such symptoms with parotidectomy in reserve.
To perform the procedure a tympanomeatal flap is
raised to expose the promontory and hypotympanum[32].
Success of tympanic neurectomy lies in complete division
of the tympanic nerve below its lowest intratympanic
branch with the corollary that promontory branches are
less significant to the success of the procedure[33]. As
such adequate exposure may require drilling of the bony
annulus inferiorly until the floor is flush with the hypo-
tympanium[33]. Drilling is required medially below the
basal turn of the cochlea to sever all nerve filaments[19]. A
comprehensive understanding of the different anatomical
segments, variations and most importantly the potential
of the tympanic nerve being partially covered in bone as
highlighted above is therefore crucial in the success of
this procedure.
ANATOMICAL SIGNPOST FOR COCHLE-
AR IMPLANTATION
In more recent years the tympanic nerve has gained fa-
vour as a useful anatomical landmark in cochlear implan-
tation where the classical approach to the scala tympani
through the round window niche by way of facial recess
is impossible[8,14]. Successful intubation of the scala tym-
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Lesser petrosal nerve
Otic ganglion
Middle meningeal artery
Branch of the
tympanic plexus
Tensor tympani
Condylar neck
Auriculo-temporal
nerve
Parotid gland
Externalcarotidartery
Figure 4 Illustration depicting the link between the
tympanic plexus (formed by the tympanic nerve) and
the parasympathetic supply to the parotid via the
lesser petrosal nerve and the otic ganglion. (Used with
permission from Dr. José M. García Santos, MD, PhD,
Head of the Radiology Department, University Hospital
Morales Meseguer, Murcia, Spain).
Kanzara T
et al
. Anatomy of the tympanic nerve
pani in such instances utilises the anatomical proximity of
the tympanic nerve to the round window and the cochlea
as has already been highlighted[8,14].
CONCLUSION
The tympanic nerve remains an anatomical area of com-
plexity that is easy to overlook yet functionally its rele-
vance to the modern clinician is ever more pertinent. It is
increasingly regarded as an important operative marker in
cochlear implantation due to its anatomical relations and
continues to retain an important role in the management
of salivary disorders. In appreciating its anatomical path,
we gain an improved understanding of the arrangement
of the middle ear and its dual relevance to both anato-
mists and surgeons.
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P- Reviewer: Hortobagyi T, Mazzocchi M S- Editor: Ji FF
L- Editor: A E- Editor: Wu HL
November 28, 2014
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Kanzara T
et al
. Anatomy of the tympanic nerve
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