Introduction: The anterior epitympanic space or anterior attic is the small space located anterior to the head of the malleus. This space has attracted the attention of ear surgeons because of its relationship to important surrounding structures and to its frequent involvement of cholesteatoma. The data reported in the literature about the anatomy of the anterior epitympanum and the tensor tympani folds are contradictory. Objectives: The aim of this article is to review the anatomy of the anterior epitympanum and tensor fold area. Methods: Ninety-eight temporal bones were studied by micro-dissection of fresh specimens. Position and insertion of the tensor fold were analyzed and anatomical details were photographed using the operation microscope. Results: In all specimens there were two structures anterior to the malleus head: the anterior epitympanic space belonging to the epitympanum, and the supratubal recess belonging to the mesotympanum. The tensor tympani fold was the separating structure between these spaces. It was intact in 65% of bones while in 35% showed a membrane defect. The more horizontal the tensor fold was, the wider the anterior epitympanic space was. Conclusions: The anterior epitympanic space and supratubal recess are two separate cavities. Removal of the tensor fold creates an efficient additional aeration route from the supratubal recess to the anterior epitympanic space. This knowledge represents the basis for any otologist in order to achieve suitable results in cholesteatoma surgery.
