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Sounds impinging on the external ear are airborne; however, the environment within the inner ear, where the sound-induced vibrations are converted to neural impulses, is aqueous. The major function of the middle ear is to match relatively low-impedance airborne sounds to the higher-impedance fluid of the inner ear. The term “impedance” in this context describes a medium's resistance to movement. Normally, when sound travels from a low-impedance medium like air to a much higher-impedance medium like water, almost all (more than 99.9%) of the acoustical energy is reflected. The middle ear (see Figure 13.3) overcomes this problem and ensures transmission of the sound energy across the air-fluid boundary by boosting the pressure measured at the tympanic membrane almost 200-fold by the time it reaches the inner ear.
Two mechanical processes occur within the middle ear to achieve this large pressure gain. The first and major boost is achieved by focusing the force impinging on the relatively large-diameter tympanic membrane on to the much smaller-diameter oval window, the site where the bones of the middle ear contact the inner ear. A second and related process relies on the mechanical advantage gained by the lever action of the three small interconnected middle ear bones, or ossicles (i.e., the malleus, incus, and stapes; see Figure 13.3), which connect the tympanic membrane to the oval window.
Bony and soft tissue, including that surrounding the inner ear, have impedances close to that of water. Therefore, even without an intact tympanic membrane or middle ear ossicles, acoustical vibrations can still be transferred directly through the bones and tissues of the head to the inner ear. In the clinic, bone conduction can be exploited to determine the source of a patient's hearing loss. For example, when a tuning fork is applied directly to the vertex of a patient's head, it is perceived as being equally loud in the two ears when there is either uni- or bilateral mechanical damage to the middle ear (conductive hearing loss) but not when there is unilateral damage to the hair cells of the inner ear or to the auditory nerve itself (sensorineural hearing loss; see Box A).